Spinal injuries 2009

Spinal injuriesSpinal injuries

GEORGE SAPKASGEORGE SAPKAS

11stst Orthopaedic Department Orthopaedic DepartmentAthens UniversityAthens UniversityAtticon HospitalAtticon Hospital

5% -10% of 5% -10% of unconscious patients unconscious patients who present to the who present to the Emergency Dept. as Emergency Dept. as the result of a M.V.A. the result of a M.V.A. or fall, have a major or fall, have a major injury to the Cervical injury to the Cervical SpineSpine

Spinal cord injury occurs in more Spinal cord injury occurs in more than 11.000/USA pts per year/USA than 11.000/USA pts per year/USA or in 40- 50 persons per millionor in 40- 50 persons per million

Injuries of the Cervical Spine Injuries of the Cervical Spine produce neurological damage in produce neurological damage in approximately 40% of patientsapproximately 40% of patients

1/3 of cervical injuries occur at the 1/3 of cervical injuries occur at the Levels CLevels C11 to C to C22

1/2 of cervical injuries occur at the 1/2 of cervical injuries occur at the levels Clevels C55 to C to C77

Most fatal cervical spine Most fatal cervical spine injuries occur in upper cervical injuries occur in upper cervical levels, either at cranio-cervical levels, either at cranio-cervical junction or at Cjunction or at C11 - C - C2 2 level.level.

Injuries of the sub Injuries of the sub --axial cervical spine axial cervical spine ( C( C33--77) are among ) are among the most common the most common and potentially and potentially most devastating most devastating injuries involving injuries involving the axial skeletonthe axial skeleton

Approximately Approximately 10% of traumatic 10% of traumatic cord injuries have cord injuries have no obvious no obvious roentgenroentgenοοgraphic graphic evidence of evidence of vertebral injuries vertebral injuries

Arterial supplyArterial supply

1.1. Anterior spinal artery (in central sulcus)Anterior spinal artery (in central sulcus)

2.2. Posterior spinal arteries (2, Posterior spinal arteries (2, posterolateral)posterolateral)

3.3. Vertebral arteryVertebral arterya.a. In foramen transversarium CIn foramen transversarium C66 C C22

b.b. Crosses posterolateral arch of CCrosses posterolateral arch of C11 (5cm (5cm from mid-line)from mid-line)

Cord Cord 1.1. Central –grey matter –cellsCentral –grey matter –cells

a.a. Anterior = 1Anterior = 1oo motor motorb.b. Posterior – 1Posterior – 1oo sensory sensory

2.2. Peripheral – tractsPeripheral – tractsa.a. Lateral spinothalamicLateral spinothalamic

i.i. Pain and temperaturePain and temperatureii.ii. Antero-lateral Antero-lateral

b.b. Lateral corticospinalLateral corticospinali.i. MotorMotorii.ii. Mid lateralMid lateral

c.c. Posterior columnsPosterior columnsi.i. Proprioception, deep pressure, Proprioception, deep pressure,

vibrationvibrationii.ii. Posterior 1/3 of cordPosterior 1/3 of cord

d.d. Orientation (medial Orientation (medial peripheral) peripheral)i.i. Arms, thoracic, legs, sarcal Arms, thoracic, legs, sarcal ii.ii. Medial portion of tracts = most Medial portion of tracts = most

proximal function (arms)proximal function (arms)iii.iii. Peripheral portion of tracts = most Peripheral portion of tracts = most

distal functiondistal function

Roots Roots 1.1. CC11- exits above C- exits above C11, body , body

2.2. CC22 a.a. Greater occipitalGreater occipital

b.b. Exits between CExits between C11 and C and C22

3.3. CC33 exits between C exits between C22 and and CC33

4.4. CC88 exits between C exits between C77 and and TT11

5.5. TT11 exits between T exits between T11 and and TT22

Pathophysiology of spinal cord injuryPathophysiology of spinal cord injury

Tator, 1996; Fehlings, 1999; Slucky, 1999; Giraldi, 1999; Ramer 2000

Primary injuryPrimary injury

Initial contusion and compression of cordInitial contusion and compression of cord

Damage to:Damage to:– neuronal cells, neuronal cells,

– axonal membranesaxonal membranes– blood vesselsblood vessels

Secondary injurySecondary injuryAn auto-destructive cascade of biomechanical An auto-destructive cascade of biomechanical events lasting hours to days that expands the events lasting hours to days that expands the zone of injuryzone of injuryIndependent or synergistic mechanisms Independent or synergistic mechanisms – Vascular Vascular

Reduced blood flowReduced blood flow Loss of autoregulationLoss of autoregulation Neurogenic shockNeurogenic shock HemorrhageHemorrhage Loss of micro-circulationLoss of micro-circulation VasospasmVasospasm thrombosisthrombosis

Secondary injurySecondary injury– Electrolyte shiftsElectrolyte shifts

Increased intracellular calciumIncreased intracellular calcium Increased extracellular potassiumIncreased extracellular potassium Increased sodium permeabilityIncreased sodium permeability

– Neurotransmitter accumulationNeurotransmitter accumulation SerotoninSerotonin CatecholaminesCatecholamines Extracellular glutamate (leads to exitotoxicity)Extracellular glutamate (leads to exitotoxicity)

– Arachidonic acid releaseArachidonic acid release– Free radical formationFree radical formation– Eicosanoid productionEicosanoid production– Lipid peroxidationLipid peroxidation– Edogenous opioid releaseEdogenous opioid release– InflammationInflammation– Loss of energy metabolism (decreased ATP)Loss of energy metabolism (decreased ATP)

Cord syndromesCord syndromes

Anterior cordAnterior cord– Anterior 2/3 of cord “not” Anterior 2/3 of cord “not”

functioning (anterior spinal functioning (anterior spinal artery)artery)

– No motorNo motor– No sharp/dull, hot/cold No sharp/dull, hot/cold

discriminationdiscrimination– Posterior columns intact: Posterior columns intact:

deep pain, prop.deep pain, prop.– Mechanism Mechanism

flexion/compression type flexion/compression type injuries, disc or retropulsed injuries, disc or retropulsed bonebone

– Limited recoveryLimited recovery

Central CordCentral CordCentral portion of cord Central portion of cord (cell bodies)(cell bodies)– Central portion of tracts Central portion of tracts

(upper extremities > lower (upper extremities > lower extremities)extremities)

– < motor in upper < motor in upper extremitiesextremities

– < sensory in upper < sensory in upper extremitiesextremities

– Better lower ext. functionBetter lower ext. function

– May have sarcal sparing May have sarcal sparing

– MechanismMechanism Extension injuriesExtension injuries Ussually elderly patients with spondylosisUssually elderly patients with spondylosis Narrow canalsNarrow canals

– CongenitalCongenital– Large osteophytesLarge osteophytes– ““Stiff” spinesStiff” spines

– Some improvement expectedSome improvement expected

Central CordCentral Cord

Brown – Sequard syndromeBrown – Sequard syndrome– Hemi – section of cordHemi – section of cord– Ipsilateral motor lossIpsilateral motor loss

Lateral corticospinal tractLateral corticospinal tract Motor cells from cord at levelMotor cells from cord at level

– Contra - lateral sensoryContra - lateral sensory Lateral spinothalamic tractLateral spinothalamic tract Axons have crossed over 1-2 Axons have crossed over 1-2

segments highersegments higher

– Ipsilateral post column function Ipsilateral post column function lossloss

– Mechanism penetrating injuryMechanism penetrating injury

– May recover significantlyMay recover significantly

– Posterior column loss (vibration, deep Posterior column loss (vibration, deep pressure, proprioception)pressure, proprioception)

– Mechanism – direct traumaMechanism – direct trauma

– Rare Rare

Posterior cordPosterior cord

– Sparing (motor and or sensory) below Sparing (motor and or sensory) below level of injurylevel of injury

– Definition level = last normal Definition level = last normal functioning levelfunctioning level

Incomplete SCIIncomplete SCI

Complete SCIComplete SCI– No motor or sensory below lesionNo motor or sensory below lesion– Spinal blockSpinal block

Cessation of reflex functionCessation of reflex function Etiology ?? Etiology ??

– Chemical/ electrophysiologic Chemical/ electrophysiologic dysfunctiondysfunction

Ends with return of B.C. reflex, anal Ends with return of B.C. reflex, anal wink or “48 hours”wink or “48 hours”

– Bulbo-cavernosus (B.C>) reflexBulbo-cavernosus (B.C>) reflex Spinal cord reflex, no central controlSpinal cord reflex, no central control 10% do not have B.C. reflex return 10% do not have B.C. reflex return

(need time period to call complete (need time period to call complete (see F-2 C)(see F-2 C)

Injuries of the upper cervical spineInjuries of the upper cervical spine(C0 – C1 – C2)(C0 – C1 – C2)

Μετεγχειρητικές ακτινογραφίες – 18mts

FRACTURES- FRACTURES- DISLOCATIONSDISLOCATIONSOF THEOF THELOWER CERVICAL LOWER CERVICAL SPINESPINE

Compression fractures are characterized by Compression fractures are characterized by failure of the anterior column under failure of the anterior column under compression with intact middle and posterior compression with intact middle and posterior columns: these are stable injuriescolumns: these are stable injuriesWhen the anterior and middle columns fall When the anterior and middle columns fall under axial loading forces, a burst fracture is under axial loading forces, a burst fracture is producedproduced

Distraction of the Distraction of the middle and posterior middle and posterior columns produces a columns produces a seat-belt type of seat-belt type of flexion distraction flexion distraction injury. These two injury. These two injury patterns can injury patterns can express varying express varying degrees of degrees of instabilityinstability

Fracture - dislocation Fracture - dislocation injuries are injuries are characterized by characterized by involvement of all involvement of all three columns in three columns in compression, compression, distraction, rotation distraction, rotation and or shear. These and or shear. These are typically grossly are typically grossly unstableunstable

Classification of spinal injuries of Classification of spinal injuries of the lower cervical spine (Cthe lower cervical spine (C33 – C – C77))

EvaluationEvaluation–RadiographicRadiographic

X-raysX-rays–AP, Lateral, swimmers AP, Lateral, swimmers

viewview–Evaluate posterior Evaluate posterior

structuresstructures–Instability patternsInstability patterns

CT - scanCT - scan–Posterior arch Posterior arch

well definedwell defined–Retropulsed Retropulsed

fragnents fragnents cord - nerves cord - nerves compromisedcompromised

–Adjacent level Adjacent level injury – 10%injury – 10%

MRIMRI– Useful to evaluate Useful to evaluate

discrepancy discrepancy between clinical between clinical evaluation and x-evaluation and x-ray / CT findingsray / CT findings

– Disc herniationDisc herniation– Ligamentous Ligamentous

injuryinjury

Treatment Treatment

Determine neurologic Determine neurologic statusstatus

Evaluate stabilityEvaluate stability

Halo brace

Operative managementOperative management

OperativeOperative– 3 column burst3 column burst

– Incomplete SCIIncomplete SCI

– Complete SCI, canal Complete SCI, canal compromise and compromise and inadequate root inadequate root recoveryrecovery

– Contraindication to Contraindication to halohalo

TimingTiming– Allow for medical stabilizationAllow for medical stabilization

– SCI dependent upon pressure and timeSCI dependent upon pressure and time

– Early ischemic changes in cordEarly ischemic changes in cord

– Earlier mobilization with surgery Earlier mobilization with surgery

– Decreased pulmonary complicationsDecreased pulmonary complications

ApproachApproach–Anterior decompression / stabilizationAnterior decompression / stabilization

–Posterior decompression / stabilizationPosterior decompression / stabilization

–Combined Combined

Anterior decompressionAnterior decompression– Traction Traction – Intraoperative distractionIntraoperative distraction– Midline troughMidline trough– Bone/disc fragment removalBone/disc fragment removal

Tear drop fracturesTear drop fractures

DefinitionDefinition– Acute flexion injury of Acute flexion injury of

the cervical spine the cervical spine characterized by characterized by compression of the compression of the vertebral body with vertebral body with anterior displacement anterior displacement of the anteroinferior of the anteroinferior cornercorner

Treatment Treatment

Non operativeNon operative– Immobilization (collar or halo)Immobilization (collar or halo)

– Neuro intactNeuro intact

– Anterior injury onlyAnterior injury only

– Compression – flexion I, II, IIICompression – flexion I, II, III

– Less than 11Less than 11oo angulation angulation

Operative treatmentOperative treatment– No neurologyNo neurology

Anterior plateAnterior plate Posterior rods - platePosterior rods - plate CombinedCombined

Neurologic deficitNeurologic deficitAnteriorAnterior

decompression, fusion, decompression, fusion, plateplate

PosteriorPosterior stabilization stabilization for significant posterior for significant posterior injury for longer injury for longer segment involvementsegment involvement

Facet fractures and Facet fractures and DislocationsDislocations

DefinitionDefinition–Disruption of Disruption of

spinal integrity spinal integrity as result of as result of flexion flexion distractiondistraction forces result in forces result in either soft tissue either soft tissue injury or fractureinjury or fracture

Bilateral facet Bilateral facet dislocationdislocation

– Significant disc Significant disc disruption in addition disruption in addition to capsular ligamnets to capsular ligamnets and posterior and posterior ligamentsligaments

– Translation (>50%)Translation (>50%)

Unilateral Unilateral ligamentous injuryligamentous injury

– Rotational componentRotational component

– Facets, spinous process Facets, spinous process rotated on one siderotated on one side

– Capsular ligament Capsular ligament disruption on dislocated disruption on dislocated side, posterior side, posterior longitudinal ligament longitudinal ligament disruption as well as disruption as well as interspinous ligament interspinous ligament disruptiondisruption

Fractures – distinct Fractures – distinct injuriesinjuries

Bilateral facet fracturesBilateral facet fractures– Superior, inferior, Superior, inferior,

combinationcombination– Translation, slight flexionTranslation, slight flexion– Best visualized with CTBest visualized with CT– Ligaments may be intactLigaments may be intact

Unilateral facet Unilateral facet fracturesfractures

– SuperiorSuperior Most commonMost common Flexion, rotationFlexion, rotation

– InferiorInferior– Fracture separation Fracture separation

of articular massof articular mass Pedicle and Pedicle and

lamina fracture lamina fracture (unilateral)(unilateral)

Treatment Treatment

Whiplash Whiplash injuriesinjuries

Extension followed by flexionExtension followed by flexionMay have severe injuriesMay have severe injuries– Cervical ligamentsCervical ligaments– Anterior or posterior musculatureAnterior or posterior musculature– Temporo – mandibular jointTemporo – mandibular joint– Esophagus/tracheaEsophagus/trachea– Difficult to diagnoseDifficult to diagnose

Recovery periodRecovery period– 3-4 days3-4 days– 3-4 weeks3-4 weeks– 6 months6 months– 2 years2 years

10% have long term pain10% have long term painRxRx– Soft collarSoft collar– Isometric strengtheningIsometric strengthening– Repeat flex/ext lateral x-rays if no Repeat flex/ext lateral x-rays if no

improvement in 3-4 weeksimprovement in 3-4 weeks

Cord contusionsCord contusions

SCISCIAll radiologic studies normalAll radiologic studies normalEtiology elastic deformation of spinal Etiology elastic deformation of spinal column within physiologic range of column within physiologic range of bone/ligaments, but beyond physiologic bone/ligaments, but beyond physiologic range of cord range of cord Rx depends on levelRx depends on level– HaloHalo– CTOCTO– CO CO

Thoraco - Thoraco - Lumbar InjuriesLumbar Injuries

ClassificationClassification

THE THREE COLUMN SPINE THE THREE COLUMN SPINE and its significance in the classification of acute and its significance in the classification of acute thoracolumbar spinal injuries.thoracolumbar spinal injuries. Denis F. Denis F. ((Spine 1983Spine 1983))

DESTRUCTIONDESTRUCTION22

out of theout of the33

COLLUMNSCOLLUMNS

MAJOR INSTABILITYMAJOR INSTABILITY

A comprehensive classification of A comprehensive classification of thoracic and lumbar injuries.thoracic and lumbar injuries.

Magerl F, Aebi M, Gertzbein SD, Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. Harms J, Nazarian S.

Eur Spine J 1994Eur Spine J 1994

Type AType A

Type BType B

Type CType C

DESTRUCTIONDESTRUCTIONof theof the

33COLLUMNSCOLLUMNS

MAXIMUM INSTABILITYMAXIMUM INSTABILITY

ROTATIONAL ROTATIONAL INJURIESINJURIES

TREATMENTTREATMENT

Check listCheck listofof

Thoraco-LumbarThoraco-Lumbarinstabilityinstability

Radiological parametersRadiological parameters

Kyphosis of the Kyphosis of the vertebral bodyvertebral body

Segmental Segmental kyphosiskyphosis

Disc heightDisc height

Vertebral body Vertebral body height:Beck indexheight:Beck index

Purposes of the operative Purposes of the operative treatmenttreatment

A.A. The stabilization of the spineThe stabilization of the spine

B.B. The decompression of the spinal cord-The decompression of the spinal cord-nervesnerves

C.C. The correction of the spinal deformityThe correction of the spinal deformity

PROCEDURESPROCEDURES

Posterior ProcedurePosterior Procedure

Anterior ProcedureAnterior Procedure

Anterior – Posterior decompression and Anterior – Posterior decompression and stabilizationstabilization one – two sessionsone – two sessions

SACRAL SACRAL

FRACTURES FRACTURES

NORMAL SACRUM & NERVE ROOTS

MRI

ZONE IAcross sacralNeurological injuries

•due to superior migration of fragments•6% of the whole•lumbrosacral plexus L5,S1 (24%)•Femoral nerve

ZONE II

• Through the neuroforamina

• Neurological injuries → L5, S1 (50%)

• Unilateral sacral anesthesia• Incontinence• Flaccid bowel and bladder• impotence

• Evaluation • Achilles reflex• Bulbocaverosus reflex• Rectal tone

ZONE III

• through the body of the sacrum

• Neurological injuries

• 56% of the whole• Cauda equina• Neurogenic bladder• Saddle anesthesia• Loss of sphincter tone• Bowel, bladder dysfunction 70%

CT - SCAN

TREATMENT

ZONE I

• Without neurologic deficits and stable

• Symptom relief

• Bed rest (7-10 days)

• Log-rolled

TREATMENT

ZONE II and III

• Without neurologic deficits

• Bed rest for 4-8 weeks

• Weight bearing at 4-8 weeks on the fractured side

TREATMENT

ZONE III

• Without neurologic deficits

• Observation: neuropraxia that will resolve

• Symptoms beyond 6-8 weeks: foraminal decompression

TREATMENT

ZONE III

• With neurologic injury

• Aggressive radiologic examination

• Early posterior

decompression

forReturn of – bowel, bladder

control

Reserval of foot drop

SURGICAL INDICATION

• posterior or vertical displacement or both (>1cm)

• Rotationally unstable pelvic ring injuries

• Sacral fractures with unstable pelvic ring that requires mobilization

• Neurological injury

PROCEDURE PRONE POSITION

PERCUTANEOUS ILIOSACRAL SCREW FIXATION

• For unilateral sacral fractures zone I or zone II

• Under fluoroscopic control the reduction is obtained and

held by iliac screws (cannulated)

OPEN REDUCTION AND INTERNAL FIXATION

UNIVERSITY HOSPITAL “ATTIKON”UNIVERSITY HOSPITAL “ATTIKON”