spine injury

1. Spinal Trauma
Mahmoud Saad M.D.
Associate Professor Neurosurgery,
Mansoura College of Medicine

2. Outline
• Relevant Anatomy.
• Epidemiology .
• Mechanisms.
• Types.
• Clinical signs.
• Radiological signs.
• Management.

3. Anatomy

4. Cervical:
Small vertebral bodies (lesser
weight bearing).
Extensive joint surfaces allows
greater ROM (rot, flex, ext).
Thoracic:
Rib bearing vertebrae.
Designed to remain stiff (minimal
flex, ext).
Lumbar:
Weight-bearing vertebrae, houses
cauda equine (min rot).
Sacral:
Transmits weight of body to the
pelvis (no motion).
Anatomy

5. Anatomy
Spinal nerve roots pass out intervertebral
foramen:
• C1-7 exit above.
• C8-L5 exit below.
Spinal nerve: ventral (motor), dorsal (sensor):
• Sensoric cells in dorsal.
• Motoric cells in Ventral horn.
Cauda equina:
• formed by L & S nerve in the spinal
canal before exiting.

7. Spine anatomy
• Anterior column - Anterior longitudinal ligament +
Anterior annular ligament and anterior half of VB.
• Middle column – Posterior long. Lig. + Posterior
annular ligament + Posterior half of VB.
• Posterior Column – Ligamentum flavum + superior
and Interspinous lig + intertransverse capsular lig +
neural arch + pedicle & spinous process.

8. Significance
• Unstable if middle column + either anterior or
Posterior column is damaged.
• Rupture of interspinous ligament :
– Associated with avulsion of spinous process.
– Unstable spine.
– Further flexion increases neurological injury.

9. Cord Segments - Vertebral Level

10. Epidemiology
 Incidence
• 11,000 new cases/year in US
– 34% incomplete tetraplegia
» central cord syndrome most common
– 25% complete paraplegia
– 22% complete tetraplegia
– 17% incomplete paraplegia
 Demographics
• Bimodal distribution
– Young individuals with significant trauma
– Older individuals that have minor trauma compounded by
degenerative spinal canal narrowing
 Location
• 50% in cervical spine

11. Most important spinal cord injury
indicator…
MECHANISM

12. Mechanisms
 MVA causes 50%
 Falls
 GSW
 Iatrogenic
• It is estimated that 3-25% of all spinal cord injuries
occur after initial traumatic episode due to improper
immobilization and transport.

13. Mechanisms
• Direct injury:
– Penetrating injuries to the spine, particularly from
firearms and knives.
• Indirect injury:
– Most common cause of significant spinal damage.
– Fall from a height  spinal column collapses in vertical
axis.

14. Common Mechanisms

15. 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
– Methylprednisone used to prevent secondary injury by
improving perfusion, inhibiting lipid peroxidation, and
decreasing the release of free radicals

16. Associated conditions
•Acute phase conditions
• Spinal shock
• Neurogenic shock
• Associated injuries
• Closed head injuries
• Noncontiguous spinal fractures
• Vertebral artery injury
• risk factors for vertebral artery injury include
• atlas fractures
• facet dislocations
• most people with unilateral injury remain asymptomatic
• imaging
• magnetic resonance angiography is least invasive method
• treatment
• stenting only if patient is symptomatic from basilar arterial
insufficiency

17. Classification
Descriptive
• Tetraplegia
• injury to the cervical spinal cord leading to impairment of function
in the arms, trunk, legs, and pelvic organs
• Paraplegia
• injury to the thoracic, lumbar or sacral segments leading to
impairment of function in the trunk, legs, and pelvic organs
depending on the level of injury. Arm function is preserved
• Complete injury
• an injury with no spared motor or sensory function below the
affected level.
• patients must have recovered from spinal shock
(bulbocavernosus reflex is intact) before an injury can be
determined as complete
• classified as an ASIA A

18. Descriptive
• Incomplete injury
– an injury with some preserved motor or
sensory function below the injury level
– Incomplete spinal cord injuries include:
• Anterior cord syndrome
• Brown-Sequard syndrome
• Central cord syndrome
• Posterior cord syndrome
• Conus medullaris syndromes
• Cauda equina syndrome

19. ASIA Classification
1. Determine if patient is in spinal shock
• Check bulbocavernosus reflex
2. Determine neurologic level of injury
• Lowest segment with intact sensation and
antigravity (3 or more) muscle function strength
• in regions where there is no myotome to test,
the motor level is presumed to be the same as
the sensory level.

20. 3. Determine whether the injury is COMPLETE
or INCOMPLETE
 COMPLETE defined as (ASIA - A)
o No voluntary anal contraction (sacral sparing) AND
o 0/5 distal motor AND
o 0/2 distal sensory scores (no perianal sensation) AND
o bulbocavernosus reflex present (patient not in spinal shock)
 INCOMPLETE defined as
o Voluntary anal contraction (sacral sparing)
o Sacral sparing critical to determine complete vs. incomplete
o OR palpable or visible muscle contraction below injury level
o OR perianal sensation present
4. Determine ASIA Impairment Scale (AIS)
Grade:

21. ASIA Impairment Scale

22. Diagnosis of spinal injuries

23. Clinical Evaluation
• Document the level of injury.
• Rule out other injuries – DPL in abdominal
injuries as there is paralytic ileus and absent
peritioneal irritation.
• Associated injuries in dorsal spine fracture are:
– Renal injuries.
– Chest and Sternal injuries.
– Wide Mediatinum due to fracture haematoma.
– Retroperitoneal injuries.

24. Level of Spinal injury
• Neurological level is at the lowest segment with
normal motor & sensory function.
• Difficult to determine:
– As most muscle efferents receive fibres from more
than one level.
– Closed cord lesions may extend over several cms.
– Dermatomes have imprecise boundaries.

25. KEY POINTS
– Every patient with a blunt injury above the clavicle, a
head injury or loss of consciousness should be
considered to have a cervical spine injury until
proven otherwise
– Every patient who is involved in a fall from a height or a
high-speed deceleration accident should similarly be
considered to have a thoracolumbar injury
– Consider the presence of a vertebral column injury in
all patients with multiple injuries
– Lesser injuries also should arouse suspicion if they are
followed by pain in the neck or back or neurological
symptoms in the limbs

26. Neurological assessment
• Sensation
• Motor function
• Reflexes
• Rectal examination

27. Neurological Assessment:
Sensory
Grading scale: 0-2
0: absent
1: impaired
2: normal
3: not testable

28. Neurological assessment: Motor
C5 :Deltoids/biceps
C6 :Wrist extensors
C7 :Elbow extensors
C8 :Finger flexors
T1 :Finger Abductors
 L2: Hip flexors
 L3: Knee extensors
 L4: Ankle dorsiflexors
 L5: Long toe extensors
 S1: Ankle plantar flexors
Grading Scale :0 - 5
0. Total paralysis
1.Palpable or visible contraction
2.Active movement; gravity eliminated
3.Active movement: against gravity
4.Active movement: against some resistance
5.active movement: against full resistance
NT: not testable

29. Bulbocavernosus reflex
• Spinal mediated reflex : S2-S4.
• Monitoring anal sphincter contraction
in response to squeezing the glans
penis or clitoris, or tugging on Foley
catheter.
• Useful in testing for spinal shock and
state of spinal cord injuries (SCI)
• Absence of the reflex indicates spinal
shock
• This is one of the first reflexes to
return after spinal shock.
• Lack of motor and sensory function
after the reflex has returned indicates
complete SCI.

30. Sacral Sparing
• Perform a rectal examination to check motor function or
sensation at the anal mucocutaneous junction.
• The presence of either is considered sacral-sparing.
• Sacral sparing triad : Perianal
sensation + rectal tone + great toe flexion
• Sacral sparing :
Present = Incomplete SCI
Absent = Complete SCI

31. Degrees of injury
• Complete - flaccid paralysis + total loss of
sensory & motor functions.
• Incomplete - mixed loss:
– Anterior sc syndrome.
– Posterior sc syndrome.
– Central cord syndrome.
– Brown sequard’s syndrome.
– Cauda equina syndrome.

35. Neurogenic shock
• Lesions above D6.
• Minutes–hours (fall of catecholamines may take 24 hrs).
• Disruption of sympathetic outflow from D1-L2.
• Unopposed vagal tone.
• Peripheral vasodilatation.
• Hypotension, bradycardia and hypothermia.
• BUT consider haemmorhagic shock if – injury below D6,
other major injuries, hypotension with spinal fracture
alone without neurological injury.

36. Spinal shock
• Transient physiological reflex depression of cord
function – ‘concussion of spinal cord’.
• Loss anal tone, reflexes, autonomic control within
24-72 hr.
• Flaccid paralysis bladder & bowel and sustained.
• Priapism.
• Lasts even days till reflex neural arcs below the level
recovers.

37. Spinal clearance – KEY POINTS
1. Spinal immobilization is a priority in
multiple trauma, spinal clearance is not
2. The spine should be assessed and
cleared when appropriate, given the
injury characteristics and
physiological state
3. Imaging the spine does not take
precedence over life saving diagnostic
and therapeutic procedures

38. Radiology
• Be thorough – adequacy, alignment, bones, cartilages and
soft tissues and distances
• SCIWORA in kids.
• Flexion injury common in lower cervical spine.
• Extension injury in upper cervical spine.
• Junction of mobile & fixed part are prone to injury e.g. C7
T1 & D12 L1.

39. Whiplash injury
• Sudden hyperextension and flexion
• Increasing neck pain for the first 24 hours
• Associated headache, pain radiating to both
shoulders and paraesthesia in hands
• Tear Anterior longitudinal ligaments → dysphagia
• Forward flexion against resistance is painful
• 90% are asymptomatic after 2 years

40. Imaging
• X-ray examination of the spine is mandatory for:
1. All accident victims complaining of pain or stiffness in the
neck or back or peripheral paraesthesiae
2. All patients with head injuries or severe facial injuries
3. Patients with rib fractures or severe seat-belt bruising
4. Severe pelvic or abdominal injuries
5. Accident victims who are unconscious
6. Elderly people
7. Patients with known vertebral pathology (e.g. ankylosing
spondylitis)

41. Imaging
• Minimum of movement and manipulation.
• X-ray  Apart from AP and lateral views:
– Open-mouth views: C1 and C2
• CT  structural damage of individual vertebrae and
displacement of bone fragments into the vertebral canal
• MRI  IV discs, ligamentum flavum and neural structures
– indicated for all patients with neurological signs and
those who are considered for surgery

42. X-ray Guidelines
 Adequacy, Alignment
 Bone abnormality, Base of skull
 Cartilage, Contours
 Disc space
 Soft tissue

43. Types of bony injury

46. The Open Mouth View
 The open mouth view should
visualise the lateral masses of C1
and the entire odontoid peg.
 Bite blocks may improve viewing.
 In the unconscious, intubated
patient the open mouth view is
inadequate and occiput to C2 CT
scan is recommended.

47. CT Scanning
 Thin cut CT scanning should be
used to evaluate abnormal,
suspicious or poorly visualized
areas on plain radiology
 The combination of plain
radiology and directed CT
scanning provides a false
negative rate of less than 0.1%

48. MRI
 Ideally, all patients with an abnormal
neurological examination should be evaluated
with an MRI scan
 Patients who report transient neurological
symptoms but who have a normal exam should
also undergo an MRI assessment of their spinal
cord

49. PRINCIPLES OF MANAGEMENT

52. Emergency treatment
• ABCDE.
• Keep warm.
• Treat if BP<80mmHg & HR <50 bpm.
• Spring loaded gardener wells calipers for traction.
• H2 Antagonists & Heparin.
• Methylprednisolone

53. Corticosteroid
National Acute Spinal Cord Injury Study I, II, and III Protocols
• Methylprednisolone bolus 30mg/kg  infusion 5.4mg/kg/h
• Infusion for 24h if bolus given within 3 hours of injury
• Infusion for 48h if bolus given within 3-8 hours after injury
• No benefit if >8h
> 8 hr  the consensus is clear that there is no indication for
steroid use

54. Immobilization

55. Principles of definitive treatment
• The objectives of treatment:
1. To preserve neurological function.
2. To minimize a perceived threat of neurological compression.
3. To stabilize the spine.
4. To rehabilitate the patient.
• The indications for urgent surgical stabilization are:
1. An unstable fracture with progressive neurological deficit
and/or MRI signs of likely further neurological deterioration
2. Controversially an unstable fracture in a patient with multiple
injuries

56. Stable vs Unstable
• Treat as unstable until proven otherwise:
• Stable injuries
– Vertebral components will not be displaced
by normal movements.
– Little risk of neural damage
• Unstable injuries
– There is a significant risk of displacement and
consequent damage – or further damage – to
the neural tissues

57. Spinal instability
Clinical:
The loss of the ability of the spine under physiologic loads
to maintain relationships between vertebrae in such a way
that there is neither damage nor subsequent irritation to
the spinal cord or nerve roots.

58. Radiological:
1. Numerous sets of radiographic criteria have been
developed in an attempt to predict which patients are or
will become unstable after a spinal injury. The most
commonly used is the three-column model of Denis.
2. The anterior column is comprised of the remaining
portions of the vertebral body and intervertebral disc,
as well as the anterior longitudinal ligament.
3. Injuries with incompetence of two or three columns are
inferred to be unstable.
4. The three-column theory applies to the thoracolumbar
spine only.

59. Unstable injury Management principles
• Initial management of the unstable spine consists of
immobilization of the injured vertebral segment while the
patient is being stabilized and other injuries are being
ruled out.

60. 3 factors for planning management decisions:
1. Need for decompression of neural elements
2. Need to mobilize the patient as soon as possible
3. Need to stabilize the spine that is not likely to heal
without surgical intervention

61. Indications for surgery
Presence of an incomplete neurologic injury with persistent
neural compression at the site of injury.
• Compression may be due to indriven bone fragments,
traumatic disc herniation, epidural hematoma, or persistent
vertebral malalignment.
• The goal of decompressive surgery is restoration of a normal
spinal canal without additional injury to the neural elements.

62. Surgical stabilization:
1.Arthrodesis, or fusion.
• To induce adjacent vertebrae above and below the injury to heal together into
a solid block of bone.
• Placement of bone graft between the vertebrae. (anteriorly, between adjacent
vertebral bodies, or posteriorly, between adjacent laminae, facets, or
transverse processes).
2. Internal fixation (instrumentation).
• maintains anatomic alignment during the time it takes for fusion to occur.
• implantation of some combination of wire, hooks, screws, and/or rods.
• Internal fixation is not a substitute for fusion.
• general principle is that all internal fixators will eventually fail if fusion does
not occur.

63. Thank you