2.  11,500 cases per
year in US
 1994: 207,000
SCI patients
 2.6% of all
admitted trauma
Summa 1999, Burnley 1993, Lasfargues 1995

3.  #1 : Male teenagers and young adults
 Relative increase in 60-70 y/o
 MVA (44.5%)
 Falls (18.1%)
 Violence (16.6%)
Summa 1999

4.  Cervical 50-64%
 Thoracic 17-19%
 Lumbar (cauda equine)
20-24%

5.  C1-C2 Facet Joints
› Horizontal plane
› Facilitates axial rotation
 Tectorial Membrane
› Continuation of PLL
› Major occip- cervical
stabilizer
› Secondary restraint for
extension of occiput on
atlas
 Alar Ligaments
Netter’s Anatomy

6.  Lateral mass:
 Consists of ipsilateral
sup/inf. facets
 Upward inclination of ~ 400
 Facet joint complex resists
anterior translation and
rotation
 Vertebral artery
 Traverses foramen in TP
 Does not traverse C7
Netter’s Anatomy

7.  Ribs and sternum limit
thoracic spine
movement; increase
stability
 Spinal cord takes up
the majority of the
canal space
 Facet joints in coronal
plane

8.  Lordotic sagittal
alignment (20-600
)
 Significant (F/E)
motion at each level
 Biplanar facet joints
 L2 -L5: Cauda Equina
Netter’s Anatomy

9. FG Fasc. Gracilis (Sensory,
lower part of cord,
Proprioceptive, Deep pain,
Vibration, Ipsilateral)
FC Fasc. Cuneatus (Sensory,
Upper part of cord,
Proprioceptive, Deep pain,
Vibration Ipsilateral)
PH Posterior Horn (Sensory cell
bodies)
AH Anterior Horn (Motor Cell
Bodies)

10. LCS Lateral Corticospinal Tract
(Crossed Pyramidal Upper Motor
Neurons to ipsi AH)
ACST Anterior Corticospinal Tract
(Direct Pyramidal go to contra AH)
PSCT ASCT Spinocerebellar Tracts
LST Lateral Spinothalamic Tract
(Sensory, Pain and Temp: cell bodies
in contra PH)
AST Anterior Spinothalamic Tract.
(Sensory, Touch: cell bodies in
contra PH)

11.  Exits through intervertebral foramen
 C1 exits between skull and atlas
 C2 to C7 exit above corresponding vertebrae
 C8 exits below C7, above T1
 Below T1; all nerves exit below corresponding
numbered vertebral pedicle

12.  Spinal nerves that have exited from the cord
 L1-L5: Nerve cell bodies lie in the cord behind T11-
T12
 S1-S5: Nerve cell bodies line within the region of
the conus medullaris
 Cauda equina nerves are more like peripheral
nerves  withstand trauma better than CNS
 Damage to this region causes LMN signs

13.  Primary mechanical insult
 Rapid compression due to bone displacement
from burst or dislocation
 Distraction ***
 Shear ***
 Penetration
 Primary injury leads to cascade of
secondary injury mechanisms
*** Portends poor prognosis !!!

14.  Vascular changes
› Diminished blood flow
› Hemorrhage
› Vasospasm
› Thrombosis
 Electrolyte shifts
 Free radical production
 Inflammatory cascade

15.  Final pathway is neuron death by:
 Cell necrosis with structural dissolution
 Apoptosis: chemical trigger initiates process that
removes non-functioning neurons but also kills
normal neurons in zone of injury

16.  Aggressive field resuscitation
› Maintain systemic BP
› Maintain optimal oxygenation
 Steroids
› NASCIS-2 8 hour window
› NASCIS-3 < 3 hrs---24 hrs;
3-8 hrs---48 hrs.
 30mg/kg bolus then 5.4mg/kg/hr
 Surgical decompression? Timing ?

17.  Complete
 Cervical tetraplegia
 Thoracic and lumbar paraplegia
 Incomplete syndromes
 Anterior cord
 Central cord
 Brown-Sequard
 Posterior cord
 Conus medullaris

18.  Definition
 No motor or sensory function more than three
segments below the neurological level of injury
 There is absence of sacral sparing

19.  Absent limb
function
 Ventilator
dependence
 C4 level may be
vent independent

20.  C5 deltoids, biceps
 C6 biceps, wrist
extension
 C7 wrist extension,
triceps
 C8 functional grasp
 T1 intrinsic hand fct
4
5

21.  Better respiratory
and trunk control
with injury at more
caudal levels
 Thoracolumbar
most commonL1
T12
12
L1

22.  L2 hip flexion
 L3/4 knee
extension
 L4 foot
dorsiflexion
 L5 EHL
 S1
gastrocsoleus
L2
L2

23.  Indicates some
continuity of long tract
fibers
 Sacral structures are
most peripheral in both
posterior columns and
lateral corticospinal
tracts
 Continued function of
sacral LMNs in conus
Skeletal Trauma

24.  Perianal sensation
(S4-S5)
dermatome
 Voluntary external
anal contraction
 Great toe flexor
activity
Skeletal Trauma

25.  Affects the anterior 2/3 of cord
 Preserves the posterior column:
proprioception, vibratory sensation
 May be due to persistent retropulsed bone
or disc material/ mechanical insult
 Vascular component

26.  Loss of all motor
and sensory below
injured level
 Deep pressure
sensation only
 Poor prognosis for
motor recovery

27.  Older patients with preexisting spondylosis
 MOI: Hyperextension injury: fall, whiplash
 Spinal cord pinched by osteophytes
anteriorly and the underlying hypertrophic
ligamentum flavum posteriorly; leads to
significant injury to the “central portion” of
the cord

28.  Best prognosis among
common patterns
 Upper extremity > lower
extremity involvement
 Distal > proximal
 Earliest and greatest
recovery in legs followed by
bladder
 Hand dexterity often slow to
return, full recovery variable

29.  Results from functional
hemisection of cord,
projectile or penetrating
wound
 Loss of ipsilateral motor
 Loss of contralateral pain,
temperature, and light
touch sensation
 75% regain independent
ambulation
 80% recover bowel and
bladder function

30.  Rare
 Loss of
proprioception
 Maintain
ambulation but rely
on visual input

31.  Direct injury to conus region (L1-L2)
 Presents as mixed lesion of cord and nerve
root damage
 Bowel, bladder, and sexual dysfunction
 Injury to CM can disrupt the
bulbocavernosus reflex arc
 Therefore, the absence of a bulbocavernosus
reflex unreliable indicator of spinal shock in this
clinical setting

32. Modified From: Lockhart RD; Hamilton GF; Fyfe FW.
Anatomy of the Human Body. JB Lippincott Company

33.  Lower motor neuron
lesion (not cord)
 Sacral segments
more affected than
lumbar
 Saddle anesthesia
with incontinence
 Lumbar sparing

34.  Common mechanism for central cord injury in
elderly—hyperextension with a spondylolytic
neck
 MRI findings impressive
 SCI protocol followed by observation until
recovery plateaus
 Treatment : same as central cord syndrome.

35. Be aware of the clinical triad of
 neurological injury and
 concomitant lamina fracture with
 burst pattern (Cammisa, 1989)---trapped
roots

36.  Decompression rarely of
benefit except for
INTRA-CANAL BULLET AT
THE T12 TO L5 LEVELS with
incomplete injury
(better motor recovery than non-
operative)
 Fractures usually stable,
despite “3-column” injury

37.  More favorable prognosis than cord injuries
 In c-spine injuries: frequently see complete
cord injury with varying levels of root injury
 Good chance of recovery of one level
 Recovery dependent on level of injury

38.  ATLS guidelines: A-B-C’s
 Examine for head, neck, or back trauma –
need to logroll
 Paradoxical diaphragmatic breathing
 Priapism
 Neurogenic shock: hypotension and
bradycardia
 Loss of sympathetic tone

39.  Log roll !!!!!
 Palpate
 Tenderness
 Gap/ Step-off
 Crepitus

40.  Motor: 0-5
 Sensory
 Rectal exam: sacral sparing?
 DTRs: LMN function
 Spinal reflexes: UMN function

42.  Biceps C5
 Brachioradialis C6
 Triceps C7
 Quadriceps L4
 Gastroc-soleus S1

43.  Perianal/perineal sensation
 Rectal tone
 Big toe flexion
 Implies partial structural continuity of white
matter long tracts
 May be only evidence of incomplete
injuryhigher chance of recovery
 Essential to check and document

44.  Bulbocavernosus
reflex:
 Pull glans or press
clitoris  anal
contraction (int.
sphincter) around
gloved finger
 Absence is indicator
of spinal shock
Skeletal Trauma

45.  Scapulohumeral reflex (C3)
 Tap on spine of scapula =>abd and elev arm
 Hoffman’s
 Inverted Radial Reflex
 Tap BR =>finger flexion (C6 root)
 Superficial abdomenal
 Cremaster
 Crossed adductor response
 Tap Medial Fem Condyle =>add contra leg

46.  Temporary loss of all or most spinal reflex
activity below level of injury
 Lasts around 24 hours (max 48 hrs)
 Ends when bulbocavernosus reflex and/or
anal wink returns
 An injury cannot be considered complete
until resolution of spinal shock

47.  Neurologic level of
injury (NLI)
› Most caudal level with
bilateral normal motor
and sensory function
 Complete/Inc
› Importance of sacral
levels
 Zone of partial
preservation

48. A Complete:
B Incomplete:
C Incomplete:
D Incomplete:
E Normal:
No motor or sensory below lesion
Sensory only below lesion to S4-5
Preserved motor below lesion, key
muscle strength < 3
Preserved motor below lesion, key
muscle strength > 3
Normal motor and sensory below
lesion -ASIA 1992

49.  X-rays
 CT
 MRI
 MRA

50.  Lateral C-spine in trauma room
› Must include down to C7-T1
› Swimmer’s view or pull-down if necessary
› Single most important radiographic examination
 C-spine series
› AP, Open mouth (dens)
 T-L-S spine films as indicated (one spine
fracture mandates full spine radiographic
evaluation)
› T-L junction: 50% of injuries occur at T11-L1

51.  Lordosis
 Unreliable sign of injury
 Prevertebral soft
tissues
 Unreliable
 No agreed upon
measure
 6 mm at C3
 22 mm at C6

52.  Anterior spinal line
› Anterior aspect of vertebral
body along ALL
 Posterior spinal line
› Posterior aspect of vertebral
body along PLL
 Spinolaminar line
› Joins the anterior margins of
the junction of the lamina and
spinous processes
 Spinous process line
› Joins tips of spinous processes

54. – Lateral masses of C1Lateral masses of C1
should align overshould align over
facet joints of C2facet joints of C2
– combined lateralcombined lateral
mass displacementmass displacement
over 7 mm suggestsover 7 mm suggests
transverse ligamenttransverse ligament
tear (Spence’s Rule)tear (Spence’s Rule)

55.  Injury suspected on plain films
 Better visualize fracture (specificity and
sensitivity)
 Unable to adequately assess on plain films
 Sagittal and/or coronal reconstructions can be
helpful (particularly at Oc.-cervical and C-T
jcts.)
 Fracture or soft tissue injury in the plane of
the CT can be missed

56.  Invaluable for assessing cord and soft tissues
 R/O associated disc herniation ( facet
dislocations)
 Hemorrhage vs edema in soft tissues ????
 Ligamentous tears and facet capsule disruptions
visualized with fat suppression
 May allow prognostic assessment of final motor
function
› Intrasubstance hematoma

57. T1 T2 GRE

59.  Roaf, 1960 – pure axial load or pure flexion
leads to little posterior ligamentous injury
 Nagel, 1981 – 20 degrees of kyphosis or 10
degrees lateral angulation implies
incompetence of PLL and posterior elements,
thus inferring instability

60.  Panjabi, 1981 – it takes sectioning of PLL and
posterior annulus to destabilize a motion
segment with the addition of facet capsule
and interspinous ligament disruption
 James et al, ’94 – middle column offers
little additional resistance to kyphosis with
increasing axial load

61.  The Issues
 Often difficult to diagnose
 Missed or delayed diagnosis can lead to
catastrophic neurologic disability
 No agreed upon protocol in the intoxicated,
multiply-injured, or head-injured patient

62.  The Problems
 Unnecessary imaging?
 Should every patient with blunt trauma gets x-rays?
 Overzealous consultation
 When and who should ‘clear the c-spine’ ??
 The Hard Collar Dilemma:
 Prolonged hard collar use leads to decubiti as well as
neck pain

63.  Hoffman, Mower, et al., NEJM 2000
 Multicenter study
 34,069 patients with blunt trauma
 AP/Lat/Open Mouth on all patients
 810 with positive x-rays
 Only 8 with false-negative x-rays
 Only 2 clinically significant

64.  Harris, Kronlage, et al. Spine 2000
 Polytrauma, intoxicated, CHI patients
 IRB Protocol: Includes intra-op flex/ext with
fluoro after all films read as normal
 Goal: Identify ligamentous injuries
 3/ 153 (+) --- all required surgical stabilization

65.  Criteria for clinical clearance
› No posterior midline tenderness
› Full pain-free active ROM
› No focal neurologic deficit
› Normal level of alertness
› No evidence of intoxication
› No ‘distracting injury’

66.  If x-rays negative, but patient c/o neck pain,
active flexion/extension x-rays when able.
Rarely helpful in acute setting
 If neurologic deficit attributable to neck
injury, immediate MRI
 Controversy over the polytrauma or
intoxicated patient remains
 EAST practice guidelines: trauma series and thin
cut axial CT through C1-2
 CT of cervical –thoracic junction if poor
visualization on plain and swimmer’s

67.  15-30% incid. uni-/bilat
 Neuro intact: MRI prior
to reduction attempt
 Neuro injured:
Reduction prior to MRI
 Neuro unknown: MRI
first
Attempt reduction without
MRI ONLY if able to
accurately monitor
neurologic exam
throughout process

68.  Experimental evidence
 Clinical evidence
 Non-operative
 Operative

69.  Numerous studies
 Classic: Tarlov 1954
 Delamarter 1995
 Dimar 1999
 Experimental models: Balloons, clips, cables,
spacers
 Beagles, rabbits, rats

70.  Severity of SCI dependent on:
 Force of compression
 Duration of compression
 Displacement, canal narrowing
 Surgical decompression does attenuate the
deleterious effects of acute SCI
 Persistent compression is a potentially reversible
form of secondary injury

71.  Most studies uncontrolled and retrospective
analyses
 Spontaneous recovery unpredictable, but
generally occurs
 Timing to reduction is important
 Most dramatic benefit in bilateral jumped
facets

72.  Surgical benefit must be weighed against
limited non-operative benefit
 Numerous studies, almost exclusively
retrospective
 Timing: early, late, and later

73.  The only prospective randomized trial
 62 patients with cervical SCI
 34 “Early” (< 72 hrs) surgery
 28 Late (> 5 days) surgery
 ASIA assessment
 No difference in neurological outcome

74.  Most studies retrospective with historical
controls
 No clear consensus on timing
 No statistical evidence that surgical
decompression influences neurologic outcome

75.  Tator et al 1999
 Retrospective, multicenter (36)
 Examined use and timing of surgery in
acute SCI
 9 month period 1994 to 1995
 All within 24 hours of injury
 16 to 75 years old
 Non-penetrating trauma

76.  585 patients
 Complete SCI in 57.8%
 Traction 47%
 Surgery 65.4%
 < 24 hrs: 23.5%
 25-48hrs: 15.8%
 48-96hrs: 19%
 > 5 days: 41.7%

77.  C-spine vs. T-L spine
 Partial vs. complete
› Spinal shock
 Definition of early surgery
 Role of steroids
 Type of decompression
› traction vs. anterior vs. posterior
 High energy vs. low energy
 Associated injuries

78. There is strong
experimental evidence
in animals to indicate:
 Decompressive surgery
of the spinal cord
improves recovery
after SCI
 Earlier surgery yields
more improvement

79. There is strong
experimental
evidence that
suggests early
decompression (<6-8
hrs) leads to a higher
likelihood of
neurological recovery.

80. Extrapolating animal
data to clinical
practice may be a
leap, but this data
comprises the
majority of current
scientific evidence.

81. The sole prospective
randomized study
concluded that there is
no difference between
early (<72 hrs) and late
(> 5 days) surgical
decompression with
respect to neurological
recovery.
Vaccaro, et al. Spine 1997