Spine injury/Trauma overview

1. SPINAL INJURY
Presented by DR Simba Fidel
MCS 2021 Candidate

2. Outlines
Definition of spinal injury
Clinical features of spinal injury
Classification of spinal injury
Pathophysiology of spinal injury
Investigations
Management
Outcome and Prognosis

3. Definition
Spinal injury is:
Injury to the Spinal column (Bony Column)/Spinal
Cord, or both of them.
Spinal injury can be divided into-
Spinal Column(Bony)Injury.
Spinal Cord injury.
Combined (Both Column& Cord) Injury.

4.  Bony injuries include:
 Compression fractures of the vertebrae
 Comminuted fractures of the vertebrae
 Subluxation (partial dislocation) of the vertebrae
 Other injuries may include:
 Sprains- over-stretching or tearing of ligaments
 Strains- over-stretching or tearing of the muscles.

5. Anatomy of the Spine

8. ◦ The three column model of spine stability

9. Epidemiology
◦ In low- and middle-income countries (LMICs), the
burden of traumatic spinal cord injury (TSCI) is largely
unknown.
◦ The estimated incidence of TSCI in LMICs is
25.5/million/year.
◦ In the US, annual incidence is approx. 54/million
population, 17810 new cases each year.
◦ Male-to-female ratio of 4:1
◦ Common among young adults from age 15-30

10. Incidence
Cervical 60%
Thoracic 8%
Thoraco-Lumbar 20%
Lumbar 10%
Sacral 2%

11. Causes

12. Pathophysiology
Primary injury
◦ damage to neural tissue due to direct trauma
◦ irreversible
Secondary injury
◦ injury to adjacent tissue due to decreased perfusion
◦ lipid peroxidation
◦ free radical / cytokines
◦ cell apoptosis

13. Patient Assessement
◦ Approach every trauma patient in the same manner
using Advanced Trauma Life Support (ATLS) principles.
◦ In polytrauma cases suspect a spinal injury.
◦ A second spinal injury at a remote level may be present
in 10% of cases.

14. ◦ There should be a high index of suspicion of
spinal injury if any of the following are evident:
◦ neurological deficit;
◦ multiple injuries;
◦ head injury;
◦ facial injury;
◦ high-energy injury (e.g. fall from a height);
◦ abdominal bruising from a seatbelt, suggestive of a
possible lumbar spine injury.

15. Clinical Evaluation
o Primary Survey
a. airway
b. breathing
SCI above C5 likely to require intubation
c. circulation
initial survey to inspect for obvious injuries of head and
spine
visual and manual inspection of entire spine should be
performed
seat belt sign (abdominal ecchymoses) should raise suspicion
for flexion distraction injuries of thoracolumbar spine

16. Evaluation CONT,…
a) Head and ear
b) Spinous process and interspinous ligaments palpation
c) Elbows may be flexed if a spinal cord injury causes loss of
function below biceps and may be extended if the paralysis
is higher.
d) Penile erection and incontinence of the bowel and
bladder- significant spinal injury.
e) Flaccid paralysis of the extremities – Quadriplegia
f) Chest abdomen and extremities – Other injuries.

17. Three categories of shock may occur in spinal
trauma:
i. Hypovolaemic shock. This presents with
hypotension, tachycardia and cold clammy
peripheries.
ii. Neurogenic shock. Hypotension, with a normal
heart rate/bradycardia and warm peripheries. It is
caused by unopposed vagal tone resulting from
cervical spinal cord injury above the level of
sympathetic outflow (C7/T1).
iii. Spinal shock. This is characterised by paralysis,
hypotonia and areflexia. It usually lasts for only 24
hours.

20. Accurate and detailed neurological evaluation – very
important
motor and reflex function.
Important dermatome landmarks are-
◦ Nipple line –T4
◦ Xiphoid process-T7
◦ Umbilicus –T10
◦ Inguinal region –T12,L1
◦ Perineum and peri-anal region (S2,S3&S4)

21. Classification
Complete injury:
◦ Total motor & sensory loss distal to the
injury after Spinal shock (usually lasts for
24-48 hrs) is over. When the bulbo
cavernosus reflex is positive & no sacral
sensation or motor function has
returned, paralysis will be permanent &
complete in most patients.

22. Incomplete injury:
◦ Some motor or sensory functions is spared distal to the
cord injury. Voluntary sphincter contraction, toe flexor
contraction –present.
◦ A spinal cord injury is incomplete when there is
preservation of perianal sensation.
◦ Prognosis is good

23. Types of incomplete SCI
◦ Central cord syndrome:
◦ This results from injury to the central portions of the
spinal cord.
◦ Distal motor function in the legs is typically spared
whereas the upper limbs and hands may be profoundly
affected.
◦ Younger patients often recover substantially but may be
left with a permanent loss of fine motor hand function.
◦ Mnemonic “Can dance but can’t play the piano”

24. ◦ Brown-Séquard syndrome
◦ This is typically seen in cord hemisection caused by
penetrating trauma.
◦ This results in ipsilateral loss of power, proprioception
and vibration sense with a contralateral loss of pain and
temperature sensation below the level of injury because
of the arrangement of the various spinal cord tracts.
◦ This type of spinal cord injury carries a good prognosis.

25. ◦ Anterior spinal syndrome:
◦ Flexion–compression injuries to the cervical spine may
damage the anterior spinal artery, cutting off the blood
supply to the anterior two-thirds of the spinal cord.
◦ Posterior column function is preserved but the
prognosis is poor.
◦ Posterior cord syndrome:
◦ This rare injury results from isolated posterior column
injury. Motor function is preserved but joint position
sense is lost.

26. ◦ Cauda Equina syndrome:
◦ This is most frequently associated with large central
herniations at L4/5 and L5/S1.
◦ Patients typically describe numbness around the
perineum and down the inside of the thighs (saddle
paraesthesia)
◦ They may also be unable to pass urine and have loss
anal tone.
◦ If possible, imaging and surgery should be undertaken
within hours of the onset of symptoms as the
deteriorates rapidly over time.

27. ◦ The extent of spinal cord injury(SCI) is defined by the American Spinal
Injury Association (ASIA) Impairment Scale (modified from the Frankel
classification), using the following categories

28. Frankel classification
◦ Five categories, i.e.
◦ No function (A),
◦ Sensory only (B),
◦ Some sensory and Motor preservation (C),
◦ Useful motor function (D),
◦ Normal (E).

29. ASIA Classification

31. Investigations
◦ Imaging:
1. X-RAY( anteroposterior, lateral, and open-mouth odontoid views. Oblique
views)
2. CT SCAN
3. MRI(it provides a detailed image of the spinal cord as well as spinal
ligaments, intervertebral discs, and paraspinal soft tissues)

33. SCIWORA (spinal cord injury without
radiologic abnormality)
◦Referred to spinal cord injury without
radiographic or CT evidence of fracture or
dislocation.
◦However with the advent of MRI, the term has
become ambiguous. Findings on MRI such as
intervertebral disk rupture, spinal epidural
hematoma, cord contusion, and hematomyelia
have all been recognized as causing primary or
secondary spinal cord injury.

37. Management
◦ Prehospital
◦ Conservative
◦ Surgery

38. ◦Initial treatment of patients with cord
injury focuses on two aspects
◦preventing further damage and
resuscitation.
◦Immobilization with a hard cervical collar
(in case of cervical spine injuries) and
care in transportation of patient is of
paramount importance if the spine is
unstable.

39. ◦ Resuscitation is aimed at airway maintenance,
adequate oxygen saturation of peripheral blood,
restoring blood pressure to acceptable limits,
preventing bradycardia, done simultaneously to
prevent any ischemic damage to the already
compromised cord

40. Non-Operative Management
◦ High dose methylprednisone
◦ Indications:
◦ nonpenetrating SCI within 8 hours of injury
◦ contraindications include
◦ GSW
◦ pregnancy
◦ under 13 years
◦ > 8 hours after injury
◦ brachial plexus injuries

41. ◦ technique
◦ load 30 mg/kg over 1st hour (2 grams for 70kg man)
◦ drip 5.4 mg/kg/hr drip
◦ for 23 hours if started < 3 hrs after injury
◦ for 47 hours if started 3-8 hours after injury
◦ outcomes
◦ leads to improved root function at level of injury
◦ may or may not lead to spinal cord function
improvement

42. ◦ Acute closed reduction with axial traction
(Skull tongs “Gardner-Wells pins”/ Halo
brace)
◦ indications
◦ alert and oriented patient with neurologic deficits and
compression due to fracture/dislocation
◦ bilateral facet dislocation with spinal cord injury in alert and
oriented patient is most common reason to perform acute
reduction with axial traction
◦ DVT Prophylaxis
◦ Cardiopulmonary management

44. Operative Management
◦ Surgical decompression and stabilization
◦ indications
◦ most incomplete SCI (except GSW)
◦ decompress when patient hits neurologic plateau or if worsening
neurologically
◦ decompression may facilitate nerve root function return at level of
injury (may recover 1-2 levels)

45. ◦ most complete SCI (except GSW)
◦ stabilize spine to facilitate rehab and minimize need for
halo or orthosis
◦ decompression may facilitate nerve root function return
at level of injury (may recover 1-2 levels).
◦ GSW with
◦ progressive neurological deterioration with retained bullet within
the spinal canal
◦ cauda equina syndrome (considered a peripheral nerve)
◦ retained bullet fragment within the thecal sac
◦ CSF leads to the breakdown of lead products that may lead to
lead poisoning

46. ◦ Cervical burst fracture with spinal cord contusion;
◦ treated by anterior decompression and reconstruction

47. ◦ Sagittal T2-weighted magnetic resonance imaging showing an L1 burst
fracture and neural compression;
◦ treated with combined anterior and posterior decompression surgery

48. Specific Spinal Injuries
◦ Upper cervical spine (skull to C2)
◦ Craniocervical dislocation
◦ Atlantoaxial instability
◦ Occipital condyle fracture
◦ Jefferson fractures (C1 ring)
◦ Odontoid fractures (types I, II, III)
◦ Hangman’s fracture

49. ◦ (Lt) Hangman’s fracture of C2 with minimal forward translation. (Rt)
C2/3 subluxation with spinal cord contusion

50. Subaxial cervical spine (C3–C7);
i. Wedge fracture
◦ This results from hyperflexion and is usually stable without
neurological injury.
◦ It is treated in a brace or halo for 3 months
ii. Burst fracture
 This occurs secondary to axial loading of the cervical spine.
Bony fragments may explode into the spinal canal and cause
neurological injury
 Burst fractures without neurological deficit can be treated
operatively in a halo jacket.

51. ◦ Tear-drop fracture
◦ The mechanism of injury is hyperextension. Unstable fractures require operative
treatment.
◦ Facet subluxation/dislocation;
◦ The majority are pure ligamentous injuries with associated disruption of the
intervertebral disc.
◦ Surgical stabilization is required.

52. Sub-axial Cervical Spine Injury
Classification System (SLICS)
◦ Classification system for subaxial cervical spine trauma that helps
determine information about
Injury pattern
Severity,
 Treatment considerations and
Prognosis

55. Thoracic and thoracolumbar fractures.
◦ Fractures that are highly unstable with an associated risk
of neurological deficit should be fixed surgically
◦ AO classification (of thoracolumbar spinal fracture)
◦ Type A: Compression injuries
◦ Type B: Distraction injuries
◦ Type C: Torsional injury
each type then broken down further into
◦ fracture morphology
◦ bony versus ligamentous failure
◦ direction of displacement

56. REHABILITATION AND PATIENT
OUTCOME
◦ The goal of spinal cord injury rehabilitation is to
maximize remaining neurological function.
◦ Despite continuing improvements in survival
following spinal cord injury, life expectancy
remains reduced.
◦ The prognosis of incomplete cord injury is highly
variable and is influenced by the type of cord
injury (syndromes), age of the patient and
associated injuries.

58. Take-Home
◦ Spinal cord injury involves both primary and secondary phases
◦ Therapeutic strategies are directed at reducing the secondary injury
◦ Use ATLS principles in all cases of spinal injury
◦ In polytrauma cases suspect a spinal injury
◦ A second spinal injury at a remote level may be present in 10% of cases.
◦ Shock after spinal injury can be hypovolaemic, neurogenic or spinal
◦ The ASIA scoring system should be used to evaluate patients with spinal
cord injury
◦ Prognoses of spinal injury depends on the type of injury
◦ Plain cervical spine radiographs fail to identity 15% of injuries

59. ◦ The management of spinal trauma depends on the presence or absence
of neurological deficit
◦ Deteriorating neurological status is an absolute indication for surgical
intervention
◦ Many spinal cord injury units no longer advocate the use of high-dose
corticosteroids.
◦ The majority of upper cervical spinal injuries are treated non-operatively
◦ Spinal cord injury is more commonly associated with subaxial cervical
spinal injuries.

60. References
◦ Bailey and Love’s Short Practice of Surgery, 25th Edition
◦ Principles of Neurosurgery, 2nd Edition
◦ Orthobullets 2017, Spine Trauma
◦ COSECSA Notes on Trauma

61. Murakoze
Thank you
Asanteni sana