Dr. Atif Shahzad

PGR Orthopaedic, SHL

Spinal injury” may be defined as-Injury to the Spinal

column (Bony Column)/Spinal Cord, or both of them.

can be divided into-

Spinal Column Injury.

Spinal Cord Injury.

Combined (Both Column & Cord) Injury.

Traumatic Spinal Cord Injury accounts for 12,000 new cases each year.

Mortality/Morbidity◦ 94% of patients survive the initial hospitalization

◦ Life Expectancy is greatly reduced. Renal Failure ,leading cause of death in the past.

Currently, Pneumonia, Pulmonary Emboli, and septicemia are the major causes.

Commonly men 16–30 years old (M:F Ratio 4:1)

Mechanism of Injury◦ Vehicle crashes: 40.4%

◦ Falls: 27.9%

◦ Penetrating trauma: 15%

◦ Sports injury: 8%

Most common vertebrae involved are

C5, C6, C7, T12, and L1 because of greatest ROM.

25% of all spinal injuries occur from improper handling of the

spine and patient after injury.

The spinal cord can be

divided into three columns:

◦ Anterior

◦ Middle

◦ Posterior.

Spinal stability is dependent

on at least two intact

columns.

When two of the three

columns are disrupted, it

will allow abnormal

segmental motion, i.e.

instability.

CERVICAL SPINE INJURIES

55% in cervical region

C-spine very flexible

Mobile & exposed

Most frequently injured area of

spine

Most injuries at C-5/C-6 level

15% in thoracic region

Less mobile & protected

Narrow spinal canal

Cord injury with minimal

displacement

Common mechanisms

Any cord damage usually

complete at this level

Most T-spine injuries occur at

T-9/T-10

15% in thoracolumbar region

Fulcrum

Transition zone prone to injury

15% in lumbosacral region

LS spine flexible nerve roots

in roomy spinal canal

May have bony injury w/o

cord or nerve root damage

Secondary injury still possible

Neurological injury rare with

isolated sacral injuries

Upper Cervical Region

Designed to facilitate motion

Canal is spacious.

Injury is uncommon

Cervicothoracic Junction

Transitional zone from mobile to fixed

Prone to injury.

Thoracic Spine

Rigid because of stabilizing influence of the thorax.

Associated vascular and visceral injuries are common.

The Thoracolumbar Junction

Transitional zone and also prone to injury.

Spinal cord injury may be categorized as:

Incomplete Quadriplegia (incomplete cervical injury)-39.5%

Complete Quadriplegia-16.3%

Incomplete paraplegia (incomplete thoracic injury)-21.7%

Complete paraplegia-22.1%

Spinal injuries can be described as:

1. Fractures

2. Fracture – dislocations

3. Spinal cord injury without radiographic abnormalities

4. Penetrating injuries

These injuries can be further categorized as stable or unstable.

Stable Injuries◦ Vertebral components won’t be displaced by normal

movement.

◦ An undamaged spinal cord is not in danger.

◦ There is no development of incapacitating deformity or pain.

Unstable Injuries◦ Further displacement of the injury may occur.

◦ Loss of 50% of vertebral height.

◦ Angulation of thoracolumbar junction of > 20 degrees.

◦ Failure of at least 2 of Denis’s 3 columns.

◦ Compression fracture of three sequential vertebrae can lead to post traumatic kyphosis.

Pattern:A.

Primary lesion occur between C5 & C7 with secondary

injuries at T12 or the lumber spine.

Pattern:B.

Primary injury at T2-T4 with secondary injury in cervical

spine.

Pattern:C.

Primary injury occur between T12 & L2 with secondary

injuries from L4-L5.

The Primary Injury

When the skeletal structures fail to dissipate the energy of the primary mechanical insult.

Direct trauma & energy transfer to neuronal elements.

Haematoma & SCIWORA < 8yrs old

In 4hrs -Infarction of white matter occurs

In 8hrs -Infarction of grey matter and irreversible paralysis.

The Secondary Injury

Hypoxia

Hemorrhage & Hypoperfusion

Oedema

Neurogenic shock secondary to the insult.

Therapeutic strategies are directed at reducing secondary injury.

Hyperextension:

Common in the neck

Anterior ligaments and disc may be damaged.

Hyperflexion:

If posterior ligament is intact , wedging of vertebral body

occurs. If torn , may cause subluxation.

Axial compression:

Causes burst fractures. Bony fragments may be pushed

into spinal canal.

Flexion with rotation:

Causes dislocation with or without fracture.

Flexion with posterior distraction:

May disrupt middle and posterior column

Bony spinal injuries may or may not be associated with spinal cord injuryBony injuries include:

◦ Compression fractures ◦ Comminuted fractures ◦ Subluxation (partial dislocation)

Other injuries may include:

◦ Sprains, over-stretching or tearing of ligaments◦ Strains, over-stretching or tearing of the muscles

Alcohol intoxication

Drug abuse

High-risk activities

Diving

Contact sports

Osteoporosis

Approach every patient in the same manner using

Advanced Trauma Life Support Principles

(ATLS).

Assume every trauma patient has a spinal injury until

proven otherwise.

All Assessment, Resuscitation and life saving

procedures must be performed with full

immobilization.

◦ Polytrauma patient

◦ Compression injury (diving, fall on buttock)

◦ Neurological Deficit

◦ Multiple Injuries

◦ Head Injuries & unconsciousness

◦ Facial Injury

◦ High energy Injury

◦ Blunt Trauma Abdomen

◦ Abdominal Bruising from a seatbelt.

◦ Spinal pain/tenderness

Activate trauma team.

Move patient off spinal board as soon as clinically safe

Airway maintenance with C-spine immobilization

Definitive airway early if respiratory compromise

Injury higher than C6 need intubation and ventilation)

Maintain hard collar, sandbag/bolsters and tape

Breathing and Ventilation

Oxygen + ventilator support

Monitor RR, respiratory effort, cough

Circulation with haemorrhage control

If hypotension – hypovolaemic vs neurogenic

shock

Assume hypovolaemia 1st : search for source blood

loss + replace fluids

- If SC injury: guide fluid replacement with CVP

monitoring (controversial)

- Inotropes may be required

- Before IDC – perform rectal examination and

assess rectal sphincter tone and sensation

Disability

- GCS /pupils

- Look for paralysis/paresis/priapism/anal sphincter tone/

bulbocavernosus reflex

Exposure/Environment

– Keep warm (blankets, fluid warmer)

Peripherally vasodilated, unable to regulate temp

if injury above T4

Full non invasive monitoring

ECG

Trauma X-ray series – lateral cervical spine, chest, pelvis

Bedside FAST scan (sources of bleeding)

NGT

IDC

Focused AMPLE Hx

Ask

Mechanism

Does your neck or back hurt?

Can you feel me touching your fingers and toes?

Can you move your hands and feet?

Assess full spine

A. Log roll and palpate spine/ paraspinal region

look for deformity/ crepitus/pain/contusions

/penetrating wounds

B. Assess for pain, paralysis and parasthesia

Location

Neurological level

Test sensation

Test motor function

Test deep tendon reflexes

DOCUMENT carefully and REPEAT

Head to toe examination – assess for associated injuries

Advanced spinal imaging:

- CT scan (defines bony injury)

- MRI scan (defines neurological injury)

Consider CVP monitoring.

◦ Spine Log Roll must be

performed to achieve

proper examination.

◦ Inspect and palpate entire

spine.

◦ Swelling, tenderness,

palpable steps or gaps

suggest a spinal injury.

◦ Note the presence of any

wounds that might

suggest penetrating

trauma.

American Spinal Injury Association neurological evaluation

system is used.

◦ Motor Function assesses key muscle groups. Grade (0-5)

◦ Sensory Function assesses dermatomal map. Pinprick and

light touch Score: 0-2

Important dermatome landmarks are

Nippleline–T4

Xiphoidprocess-T7

Umbilicus–T10

Inguinalregion–T12,L1

Perineum and perianal region (S2,S3&S4)

◦ Deep Tendon Reflexes

◦ Rectal examination:

Anal tone.

Voluntary anal contraction.

Perianal sensation.

What should be known after complete neurological

examination?

◦ Presence or absence of neurological injury.

◦ Probable level of injury.

◦ Injury is complete or incomplete.

◦ Level of impairment.

Pain (and bony tenderness on examination)

Tingling, numbness and weakness in peripheries

Loss of sensation or paralysis below level of injury

Impaired breathing – C3/4/5 (diaphragm)

Incontinence

Priapism

“Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function.

Motor level = the last level with at least 3/5 (against gravity) function

This is the most important for clinical purposes

Sensory level = the last level with preserved sensation

Radiographic level = the level of fracture on plain X-Rays/ CT scan / MRI

Spine level does not correspond to spinal cord level below the cervical region.

Loss of neural tissue –obvious.

Vertical level –Higher up, greater the damage.

Transverse plane –What Diameter has a lesion.

Spinal shock may mimic a complete cord lesion with total loss

of motor & sensory function distal to injury. However if lesion

is incomplete some function will return

99% of patients with a complete lesion over 24 h will not

show functional recovery

Patients with partial lesion may regain substantial or even

normal neurological function even though the initial

neurological deficit may be severe

Presence of bulbocavernousreflex or anal-cutaneous reflex

indicates sacral sparing and a more favorable prognosis.

The bulbocavernosus

reflex (BCR) is a

polysynaptic reflex

that is useful in testing

for spinal shock and

gaining information

about the state of

spinal cord injuries

(SCI)

BULBOCAVERNOSUS REFLEX

LOCATION OF INJURY

POSSIBLE EFFECTS

At or above C5 Respiratory paralysis and quadriplegia

Between C5& C6 Paralysis of legs, wrists, and hands; weakened shoulder abduction and elbow flexion; loss of brachioradialis reflex

C6-C7 Paralysis of legs, wrists, and hands, but shoulder movement and elbow flexion usually possible; loss of biceps jerk reflex

C7-C8 Paralysis of legs and hands

C8-T1 With transverse lesions, Horner's syndrome (ptosis, miotic pupils, facial anhidrosis), paralysis of legs

T1-T12 Paralysis of leg muscles above and below the knee

At T12 to L1 Paralysis below the knee

Cauda equina Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of the nerve roots, and usually loss of bowel and bladder control

At S3-S5 or conus medullaris at L1

Complete loss of bowel and bladder control

Level Of Muscle Group

C5 Elbow flexors (biceps, brachialis)

C6 Wrist extensors (extensor carpi radialis longus and

brevis)

C7 Elbow extensors (triceps)

C8 Finger flexors (flexor digitorum profundus to middle

finger)

T1 Small finger abductors (abductor digiti minimi)

L2 Hip flexors (iliopsoas)

L3 Knee extensors (quadriceps)

L4 Ankle dorsiflexors (Tibialis anterior)

L5 Long toe extensors (extensor hallucis longus)

S1 Ankle plantar flexors (gastrocnemius, soleus)

85% of significant spinal injuries will be seem on standard lateral cervical spine.

CT Scan should be obtained. ◦ Most Sensitive in spinal trauma. ◦ Complex patterns and fractures can be understood.

MRI◦ Best at visualizing soft-tissue elements of the spine. ◦ Possible to view spinal cord hemorrhage, epidural and

prevertebral hematomas. ◦ Not good at assessing bony structures.

In spinal traumas radiographs and CT scans usually give sufficient information and MRI is not required.

Spinal cord injury without radiographic or CT evidence of

fracture or dislocation

With advent of MRI, term has become

"Spinal cord injury without neuroimaging abnormality" more

correct name.

Mostly in pediatric population ( Birth to 16 years)

Common in cervical and thoracic region

Following findings on MRI have been recognized as

causing primary or secondary spinal cord injury:

-Intervertebral disk rupture

-Spinal epidural hematoma

-Cord contusion

-Hematomyelia

Prognosis of SCIWORA is actually better than patients

with spinal cord injury and radiologic evidence of

traumatic injury.

Objectives Stabilize the spine.

To prevent further trauma

Preserve neurological function.

Relieve reversible nerve or cord compression.

To observe symptoms of progressive neurologic deficit.

To improve sensory and perceptual awareness

Prevention of complications

Promote comfort

Rehabilitate the patient.

An important goal is to prevent secondary injury to the spine or spinal cord.

Emergency Department acute care is to avoid

secondary spinal injury

Protection Priority

Detection Secondary

1. Immobilization

2. Intravenous fluids

3. Medications

4. Early advise, prompt referral/

transfer

Fluid resuscitation

• Maintenance fluids only unless shock ,MAP 85-90 mmHg

• If shocked – establish if hypovolaemic OR neurogenic

Insert IDC

• Monitor urinary output

• Prevent bladder distension

Insert NGT

• Prevent gastric distension (+/- paralytic ileus)

• Prevent aspiration (sphincter paralysis)

Medications Corticosteroids - insufficient evidence for routine use

Reducing extent of permanent paralysisHigh dose methylprednisoloneImproved motor neurological outcome if given within 8 hours.Given as bolus dose and then IV infusion for 24-48 hours

- 24 hour IVI if Tx within 3 hours of injury- 48 hours IVI if Tx within 3-8 hours of injury

Increased risk of sepsis due to immunosuppressive effectsCI: heavily contaminated open injuries, perforated bowel, sepsis

Consult with spinal specialist.

AnalgesiaOpiates and NSAIDS.

The goals of operative treatment Decompress the spinal cord canal

Stabilize the disrupted vertebral column.

Fixation of Vertebra

Fixation of Spine

Artificial disc implantation.

The 4 basic types of stabilization procedures are 1. Posterior lumbar interspinous fusion,

2. Posterior rods

3. Cage

4. The Z-plate anterior thoracolumbar plating system. Each has different advantages and disadvantages.

With no neurological deficit:

If stable-pain relief , collar or brace.

If unstable-reduce and hold secure until bone / ligaments heal with surgery or traction.

With complete sensory or motor loss:

Usually an unstable injury

Only consider conservative management for high thoracic injuries.

Early operative stabilization to help with nursing , prevent spinal deformity and pain.

Speeds up rehab.

With incomplete neurological loss:

Stable injury-conservative bed rest , brace.

Unstable injury-early reduction and stabilization.

COMPLETE Neurology

Total flaccid paralysis

Total anaesthesia

Total analgesia

No tendon reflexes

MUST WAIT UNTIL SPINAL SHOCK RESOLVED to diagnose

INCOMPLETE Neurology

Partial paralysis

Altered sensation (light touch or pin prick)

Sacral sparing

BETTER prognosis, may recover

Improperly sized C-Collar

Spine not supported due to improper positioning on

backboard

Inadequate strapping allows excessive movement

Movement possible due to little or no padding to shim the

body

C-spine movement by inadequate or improperly applied

head immobilization device

C-spine hyperextension due to improperly applied C-collar

or head immobilization devicE

Readjusting torso straps after immobilization of the head,

causing misalignment of the spine

Securing head to backboard prior to securing shoulders,

torso, hips, and legs

THANKS