1. INJURIES OF THE SPINE
02/02/14
Presenter : MSIGWA SAMWEL S - MD5
(University of Dodoma-Tanzania)
Moderator:
D r . MANYAMA-ORTHOPAEDICS
SURGEON
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2. Outline
Introduction and Epidemiology
Anatomy
Mechanism of Injury
Classification of Spinal cord injuries
Clinical evaluation
Treatment
Complications
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3. INTRODUCTION
Fractures and dislocations of t he spine
are serious injuries because they may be
associated with damage to the spinal cord
or cauda equina.
The thoraco-lumbar segment is the
commonest site of injury; the lower
cervical being the next common.
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4. About 20 per cent of all spinal injuries
result in a neurological deficit in the form
of paraplegia in the thoraco-lumbar spine
injuries, or quadriplegia in the cervical
spine injuries.
Often, the patient does not recover from
the deficit, resulting in prolonged
invalidism or death.
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5. Globally
Globally
Affects 10,000 a year
Age group-16-30 years
Male: female=4:1
Automobile accidents are the most
common cause in person <65 years
Falls are the most common cause in
person>65years
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6. Tanzania
In TZ the research done at BMC 2012
showed that among the SI resulted from
road traffic crashes most of them were
caused by Motorcycle (58.8%) .
Spine injuries was 0.7% out of all Injuries.
Male to female ratio was of 2.1:1
The modal age group was 21-30 years,
accounting for 52.1% patients.
Students (58.8%) and businessmen
(35.9%) . Mortality rate was 17.5%.
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7. Basic Anatomy of the Spine
1.Structure:
Extends from the skull to the tip of the
coccyx, consisting of 33 vertebrae:
Cervical(7), Thoracic(12), Lumbar(5),
Sacral(5) and Coccygeal(4)
Has 4 curvatures: cervical and lumbar
(concave anteriorly), thoracic and sacral
(concave posteriorly)
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9. Structure of a Typical Vertebra
 Vertebral body
Epiphyseal ring and central cancellous bone
 Neural arch
2 pedicles and 2 laminae
 7 Processes
A spinous
2 transverse
2 superior articular
2 inferior articular
 Vertebral foramen & canal
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11. Atlas (C1)
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12. Axis (C2)
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13. Lumbar Vertebra
Superior view
.
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14. Lumbar Vertebra
Lateral view
 .
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15. Thoracic Vertebra
Lateral view
 .
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16. 2.Articulation:
The entire vertebral column has similar
articulation (except atlanto-axial joint).
The v e r t e b r a l bodies are primarily joi
n e d by intervertebral discs.
Anteriorly, the vertebral bodies are
connected to one another by a long, straplike, anterior longitudinal ligament,
Posteriorly by a similar posterior
longitudinal ligament.
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17. Accessory Ligaments of the
Intervertebral Joints
 Ligamentum flavum
Between lamina of adjacent vertebrae
 Supraspinous
Between tips of spinous processes
 Interspinous
Connects adjacent spinous processes
 Nuchal
Occipital protuberance and foramen magnum to cervical vertebrae
 Intertransverse
Connects adjacent transverse processes
NB:These ligaments are together often termed the posterior
ligament complex.
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18. Saggittal Section Thru 2 Vertebrae
.
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19. Three-column concept
The anterior column consists of the
anterior longitudinal ligament and the
anterior part of annulus fibrosus along with
the anterior half of the vertebral body.
The middle column consists of the
posterior longitudinal ligament and the
posterior part of the annulus fibrosus
along with the posterior half of the
vertebral body.
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20. a) Anterior column
b) Middle column
c) Posterior column
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21. The posterior column consists of the
posterior bony arches along with the
posterior ligament complex.
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22.  Joints of the vertebral bodies
Intervertebral discs which consist of annulus fibrosus and nucleus pulposus
Anterior and posterior longitudinal ligaments
 Joints of the neural arches
 Atlantoaxial joints
 Atlanto-occipital joints
 Costovertebral joints
 Sacroiliac joints
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23. Simple General Classification
Based on 3 Column concept
Stable fractures
Is one where further displacement
between two vetebral bodies does not occur
because of the intact 'mechanical linkages'.
When only one column is disrupted (e.g., a
wedge compression fracture of t h e
vertebra) the spine is stable.
 Posterior ligament complex, neural arch
and articular facets intact; only vertebral
bodies and anterior ligament complex
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24. Unstable fractures
Is one where further displacement can
occur b e c a u s e of serious disruption of
the structures responsible for stability.
When two columns are disrupted (e.g., a
burst fracture of the body of the vertebra)
the spine is considered u n s t a b l e .
When all the t h r e e columns are
disrupted, the spine is always unstable (e.g.,
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dislocation of one vertebra over other).
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25. 3.Spinal cord
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26. Dorsal root – sensory fibres
Ventral root – motor fibres
Dorsal and ventral roots join at
intervertebral foramen to form the spinal
nerve
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28. Physiology and function
Grey matter – sensory and motor nerve
cells
White matter – ascending and descending
tracts
 Divided into - dorsal
- lateral
- ventral
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30. Ascending and descending
pathways
Connection between cerebrum and body
(muscle, sensation)
Corticospinal/pyramidal tract = voluntary
movement
Dorsal columns = vibration, proprioception and
fine touch
Lateral spinothalamic = pain and temperature
Anterior spinothalamic = pressure and crude
touch
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32. Dermatomes
Area of skin innervated by sensory axons
within a particular segmental nerve root
Knowledge is essential in determining
level of injury
Useful in assessing improvement or
deterioration
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Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
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34. Myotomes :
Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
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35. Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
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36. Denis Classification
Based on 3 Column Concept
1.
Anterior column; ant. Long. Ligament, ant ½ of annulus
and vertebral body
2.
Middle column; post. Long. Ligament and post ½ of
annulus and vertebral body
3.
Posterior column; spinous processes, facet joints and
capsule, supra and inter spinous ligaments
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37. Basic Types of Spine Fractures
and their Mechanisms
1• Flexion-injury
2• Flexion-rotation injury
3• Vertical compression injury
4• Extension injury
5• Flexion-distraction injury
6• Direct injury
7• Indirect injury due to violent muscle
contraction
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38. 1. Flexion injury
This is the
commonest spinal
injury.
Examples:
(i) heavy blow across
the shoulder by a
heavy object
(ii) fall from height on
the heels or buttocks
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39. Results
In the cervical spine, a flexion force can
result in:
(i) a sprain of the ligaments and muscles
of t he back of t he neck:
(ii) compression fracture of
the vertebral body, C5 to C7
(iii) dislocation of one vertebra over another
(commonest C5 over C6).
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40. In the dorso-lumbar spine, this force can
result in
The wedge compression of a vertebra
(L1commonest followed by L2 and T12).
It is a stable injury if compression of t he
vertebra is less than 50 per cent of its
posterior height.
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41. 2. Flexion-rotation injury:
This is the worst type
of spinal injury
because it leaves a
highly unstable spine,
and is associated with
high incidence of
neurological damage.
Examples:
(i) heavy blow onto
opposite side
one shoulder causing (ii) a blow or fall on posterolateral
aspect of the head.
the trunk to be in
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42. Results
In the cervical spine this force can result
(i) dislocation of the facet joints on one or both
sides
(ii)(ii) fracture-dislocation of the cervical
vertebra.
 In the dorso-lumbar spine
A fracture-dislocation of the spine.
Here one vertebra is twisted-off in front of the one
below it. There i s extensive damage to the
neural arch and posterior ligament complex. It is
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43. 3. Vertical compression injury
It is a common spinal
injury.
Examples:
(i) A blow on the top of
the head by some
object falling on the
head
(ii) a fall from height in
erect position
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44. RESULTS
In the cervical spine, this force results in
A burst fracture i.e., the vertebral body is
crushed throughout its vertical dimensions. A
piece of bone or disc may get displaced into the
spinal canal causing pressure on the cord.
In the dorso-lumbar
spine, this force results in a fracture similar to
that in the cervical spine, but due to a wide canal
at this level, neurological deficit rarely occurs. It
is an unstable injury.
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45. Extension injury:
This injury is commonly
seen in the cervical
spine.
Examples:
(i) motor vehicle accident
— the forehead striking
against the windscreen
forcing the neck into
hyperextension
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(ii) shallow water diving
—the
head hitting the ground,
extending the neck
Results: This injury results
in a hip fracture of
the anterior rim of a
vertebra. Sometimes, these
injuries may be unstable.
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47. 4. Flexion-distraction injury:
This is a recently described spinal injury,
being recognised in Western countries
where use of a seat belt is compulsory
while driving a car (chance fracture)
Example:
With the sudden stopping of a car, the
upper part of t h e body is forced forward by
inertia while the lower part is tied to
the seat by the seatbelt.
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49. 5. Direct injury
This is a rare type of
spinal injury.
Examples:
(i) bullet injury; (ii) a
lathi blow hitting the
spinous processes of
the cervical vertebrae.
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Results:
Any part of the
vertebra may be
smashed by a bullet,
but, a lathi blow
generally causes a
fracture of t he
spinous processes
only.
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50. 6.Violent muscle contraction
This is a rare injury.
Example: Sudden
violent contraction of
the psoas.
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Results: It results in
fractures of the
transverse processes
of multiple lumbar
vertebrae.
It may be a s s o c i a
t e d with a huge
retroperitoneal
haematoma.
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51. Spinal Column Injury
1. Cervical Spine Injuries
Causes:
–Fall from
height
–Diving
accident
–Whiplash
injury
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Mechanism
 Flexion
 Flexion and
rotation
 Extension
 Compression
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52. Occipito – Atlantal Dislocation
Fatal
Subluxation without ND may survive
Early & correct diagnosis with CT scan or
MRI
Dx by lateral cervical radiograph
Tip of odontoid from basion: Alignment
<5mm vertically & <1mm horizontally
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53. OAD Imaging
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54. OAD Imaging
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55. OAD Treatment
Initially by halo immobilisation without
traction
Definitive: posterior occipito – cervical
fusion
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57. Atlas (C1) fractures
Described as Jefferson #
Axial load
Usually no neurological
deficit
1/3 have C2 #
Usually stable
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58. C1 fracture – Treatment
Lateral masses
– Undisplaced stable #s:
semi rigid collar or halo –
vest until it unites
– Displaced: side ways
spreading > 7mm; unstable
& may require posterior
C1/2 arthrodesis
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60. Axis (C2) #
Includes Hangman’s #
and Odontoid process #
HANGMAN’S #
Bilateral # of the isthmus
of the pedicles of C2 with
anterior sublaxation of
C2-C3
Hyperextention and axial
loading
Usually stable
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61. Spinal Column Injury
Axis (C2) #
Includes Hangman’s
# and Odontoid
process #
I
Odontoid #
Flexion injury
15% of all cervical
injuries
II unstable,I & III
stable
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II
III
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62. Odontoid Fracture (C2)
Anderson & D’Alonzo
classification:
Type 1 – An avulsion
fracture of tip of odontoid
process due to traction of
alar lig.
Type 2 – # at the junction
of odontoid process and
the body. Most common
& potentially dangerous
type
Type 3 – # thru the body
of axis
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63. Odontoid Fracture Cont’d
Treatment
Type 1 – Mobilise in rigid
collar 8-12 wks
Type 2
– Undisplaced #s: halo –
vest for 8-12 wks
– Displaced : Skull traction
then wiring or screw
fixation
Type 3 – Traction or halovest depending on
whether displaced or not
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64. Spinal Column Injury
Subaxial (C3-C7) #
Whiplash injury:
 Traumatic injury to the
soft tissue in the cervical
region
 Hyperflexion,
hyperextention
 No fractures or
dislocations
 Most common automobile
injury
 Recover 3-6 months
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65. Whiplash Injury
X ray: loss of cervical lordosis due to muscle
spasm
MRI: disc herniation
Cervical collar and graded exercises
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66. Spinal Column Injury
Subaxial (C3-C7) #
Vertical compression
injury:
 Loss of normal cervical
lordosis
 Burst #
 Compression of spinal
cord
 Unstable
 Requires decompression
and fusion
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67. Spinal Column Injury
Subaxial (C3-C7) #
Compression flexion
injury (teardrop #)
 Classical diving injury
 Posterior elements
involved in >50%
 Displacement of inferior
margin of the body
 Unstable
 Requires stabilization
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68. Spinal Column Injury
Subaxial (C3-C7) #
flexion distraction injury
(locked facet)
 >50% displacement
 Unstable
 Requires reduction and
stabilization
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69. Spinal Column Injury
Subaxial (C3-C7) #
extention injury (#
posterior elements)
 # lamina, pedicles or
spinous process
 With or without
ligamentous injury
 Usually stable
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70. Clay Shoveller’s Injury
Fracture of C7 spinous process with
severe voluntary contraction of back
muslces
Painful but harmless
Only analgesia
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71. Spinal Column Injury
Thoracic and lumbar #
Stability (three column
model of Denis)
 Injury affecting two or
more column is unstable
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72. Spinal Column Injury
Thoracic and lumbar #
Compression #
Burst #
Chance # (seat belt)
Flexion distraction
Fracture dislocation
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73. Wedge Compression Fracture
Stable injury affecting
only ant. column
Semi – rigid collar
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74. Posterior Lig. Injury
Sudden flexion of mid cervical spine
Damage to post. lig. Complex
Upper vertebra tilts forward on one below
& opening interspinous space
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75. Posterior Lig. Injury Cont’d
Treatment
Unstable:
– Angulation of VB with its neighbour >11º
– Anterior translation of a vertebra >3.5mm
– # or dislocation of facet
Treated with post. fixation & fusion
Stable
– Semi – rigid collar x 6wks
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76. Burst Fracture
Axial loading as in diving
or athletic accidents
Comminuted fracture of
vertebral body
Frag. may enter spinal
canal
Halo vest or anterior
decompression if
neurological deficit
present & immobilisation
x 6-8 wks
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77. Cervical Disc Herniation
Severe pain radiating upper limbs
Paresthesia and weakness may be
present
If there is paresis, then decompression is
indicated – ant discectomy & interbody
fusion
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78. Signs and symptoms
The extent of injury is defined by the
American Spinal Injury Association (ASIA)
Impairment Scale (modified from the
Frankel classification), using the following
categories.
A – Complete: no sensory or motor function
preserved in sacral segments S4 – S5
B – Incomplete: sensory, but no motor
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79. C – Incomplete: motor function preserved
below level and power graded < 3
D – Incomplete: motor function preserved
below level and power graded 3 or more
E – Normal: sensory and motor function
normal

80. Spinal Shock vs Neurogenic Shock
Spinal Shock :
 Transient reflex depression of cord function below level
of injury
 Initially hypertension due to release of catecholamines
 Followed by hypotension
 Flaccid paralysis
 Bowel and bladder involved
 Sometimes priaprism develops
 Symptoms last several hours to days

81. Neurogenic shock:
Triad of i) hypotension
ii) bradycardia
iii) hypothermia
More commonly in injuries above T6
Secondary to disruption of sympathetic
outflow from T1 – L2

82. Loss of vasomotor tone – pooling of blood
Loss of cardiac sympathetic tone – bradycardia
Blood pressure will not be restored by fluid
infusion alone
Massive fluid administration may lead to
overload and pulmonary edema
Vasopressors may be indicated
Atropine used to treat bradycardia

83. Neurogenic Shock
Hypovolemic Shock
As the Result of Loss of Sympathetic
Outflow
As the Result of Hemorrhage
Hypotension
Hypotension
Bradycardia
Tachycardia
Warm extremities
Cold extremities
Normal urine output
Low urine output
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84. Types of incomplete injuries
i)
Central Cord Syndrome
ii)
Anterior Cord Syndrome
iii)
Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v)
Cauda Equina Syndrome

85. i)
Central Cord Syndrome :
 Typically in older patients
 Hyperextension injury
 Compression of the cord anteriorly by
osteophytes and posteriorly by
ligamentum flavum

86. Also associated with fracture dislocation
and compression fractures
More centrally situated cervical tracts tend
to be more involved hence
flaccid weakness of arms > legs
Perianal sensation & some lower extremity
movement and sensation may be
preserved

89. ii) Anterior cord Syndrome:
Due to flexion / rotation
Anterior dislocation / compression fracture
of a vertebral body encroaching the
ventral canal
Corticospinal and spinothalamic tracts
are damaged either by direct trauma or
ischemia of blood supply (anterior spinal
arteries)

90. Clinically:
Loss of power
Decrease in pain and sensation below
lesion
Dorsal columns remain intact

92. ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures
of the posterior elements of the vertebrae


Clinically:
Proprioception affected – ataxia and
faltering gait
Usually good power and sensation

93. ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures
of the posterior elements of the vertebrae


Clinically:
Proprioception affected – ataxia and
faltering gait
Usually good power and sensation

94. iv) Brown – Sequard Syndrome:
Hemi-section of the cord
Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
Fractures of lateral mass of vertebrae

95. Clinically:
Paralysis on affected side (corticospinal)
Loss of proprioception and fine
discrimination (dorsal columns)
Pain and temperature loss on the opposite
side below the lesion (spinothalamic)

97. v) Cauda Equina Syndrome:

Due to bony compression or disc protrusions
in lumbar or sacral region
Clinically
 Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia

98. INVESTIGATIONS
Good ante-posterior and lateral X-rays
centring on the involved segment provide
reasonable information about the injury.
Sometimes, special imaging techniques
are required e.g., Tomogram, C.T. scan,
M.R.I,
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99. Plain X-rays:
(i) confirmation of diagnosis
(ii) assessment of mechanism of injury and
(iii) assessment of the stability of the spine.
The following features may be noted on plain Xrays
• Change in the general alignment of the spine
i.e., antero-posterior bending (kyphosis) or sideways
bending (scoliosis).
• Reduction in t h e height of a vertebra.
• Antero-posterior or sideways displacement of one
vertebra over another.
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• Fracture of a vertebral body. • Fracture of t h e
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100. C.T. scan and M.R.I
C.T. scan h a s proved to be a very helpful
investigation. One can see the damaged
structures more clearly, and make note of
any bony fragment in the canal.
M.R.I. is the best modality of imaging an
injured spine.
In addition to showing better, the details
of injured bones and soft-tissues,it shows
very well the anatomy of t he cord.
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101. Tomogram:
A tomogram helps in better delineation of
a doubtful area. Myelogram has no role in
the management of acute spinal injuries.
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102. MANAGEMENT
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103. The treatment of spinal injuries can be
divided into three phases, as in other
injuries:
Phase I: Emergency care at the scene of
accident or in emergency department.
Phase II: Definitive care in emergency
department or in the ward.
Phase III: Rehabilitation
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104. Phase I - At the scene of accident
An acute pain in the back following an injury is to
be considered a spinal injury unless proved
otherwise.
Also, all suspected spinal injuries are to be
considered unstable unless their stability is
confirmed on s u b s e q u e n t investigation.
NB: A patient with a spinal injury has to be given
the utmost care right at the scene of accident;
the basic principle being to avoid any movement
at the injured segment.
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105. While moving a person with a suspected cervical
spine injury, one person should hold the neck in
traction by keeping the head pulled.
 The rest of the body is supported at the
shoulder, pelvis and legs by three other people.
Whenever required, the whole body is to be
moved in one piece so t h a t no movement
occurs at the spine.
 The same precaution is observed in a case with
suspected dorso-lumbar injury.
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106. In the emergency department
The patient should not be moved from the
trolley on which he is first received until
stability of t he spine is confirmed
A quick general examination of t h e
patient is carried out in order to detect any
other associated injuries to the chest,
abdomen, pelvis, limbs etc.
The spine i s examined for any
tenderness, crepitus or haematoma.
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107. PHASE II - DEFINITIVE CARE
Definitive care of a patient with spinal injury
depends upon the stability of the spine and the
presence of a neurological deficit.
The aim of treatment is:
(i) to avoid any deterioration of the neurological
status;
(ii) to achieve stability of the spine by conservative or
operative methods
(iii) to rehabilitate the paralysed patient to the best
possible extent.
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108. Treatment of cervical spine
injuries
Cervical spine injuries are often associated
with head injuries, the effect of which may
mask the spinal lesion.
Therefore, it is necessary to get an X-ray of
the cervical spine in any serious case of
head injury.
The aim of treatment is to achieve proper
alignment of vertebrae, and maintain it in that
position till the vertebral column stabilises.
This can be achieved in most cases by
conservative methods. In some cases, an 108
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operation may be required for-reducing or stabilising the spine.

109. Reduction
is achieved by skull traction applied
through skull calipers—Crutchfield tongs
A weight of up to 10 kg is applied and
check X-rays taken every 12 hours
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111. Operation:
This may be required for:
(i) irreducible subluxation because of
'locking' of the articular processes or
(ii) persistent instability.
The operation consists of inter-body fusion
(anterior fusion) or fusion of the spinous
processes and laminae (posterior fusion).
Internal fixation may be required.
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112. Treatment of thoracic and
lumbar spine injuries
Operative methods:
Whenever necessary the following
operative methods are performed
• Harrington instrumentation — bilateral.
• Luque instrumentation.
• Hartshill rectangle fixation.
• Pedicle screw fixation.
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113. References:
1. Andrew T Raftery, et al. Applied Basic Science for
Basic Surgical Training. Second edition 2008;8:219223
2. Essential Orthopaedics 3rd EDITION-Maheshwari
3. Handbook of Fractures 3rd Edition
4. Dr.Ferdinand Massaga-UDOM,classnotes
5. Spinal cord injuries-JC King
6. Muhas presentation

114. Thank you
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