Msigwa spinal injuries

INJURIES OF THE SPINEINJURIES OF THE SPINE

Presenter : MSIGWA SAMWEL S - MD5 Presenter : MSIGWA SAMWEL S - MD5 (University of Dodoma-Tanzania)(University of Dodoma-Tanzania)

Moderator:Moderator:

D r . MANYAMA-ORTHOPAEDICS D r . MANYAMA-ORTHOPAEDICS SURGEONSURGEON

22/01/201422/01/201404/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 11

OutlineOutline

Introduction and EpidemiologyIntroduction and Epidemiology

AnatomyAnatomy

Mechanism of InjuryMechanism of Injury

Classification of Spinal cord injuriesClassification of Spinal cord injuries

Clinical evaluationClinical evaluation

TreatmentTreatment

ComplicationsComplications

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INTRODUCTIONINTRODUCTION

Fractures and dislocations of t he spine Fractures and dislocations of t he spine are serious injuries because they may be are serious injuries because they may be associated with damage to the spinal cord associated with damage to the spinal cord or cauda equina. or cauda equina.

The thoraco-lumbar segment is the The thoraco-lumbar segment is the commonestcommonest site of injury; the lower site of injury; the lower cervical being the next common.cervical being the next common.


About About 20 per cent 20 per cent of all spinal injuries of all spinal injuries result in a neurological deficit in the form result in a neurological deficit in the form of of paraplegiaparaplegia in the thoraco-lumbar spine in the thoraco-lumbar spine injuries, or injuries, or quadriplegiaquadriplegia in the cervical in the cervical spine injuries. spine injuries.

Often, the patient does not recover from Often, the patient does not recover from the deficit, resulting in prolonged the deficit, resulting in prolonged invalidism or death.invalidism or death.


GloballyGlobally

GloballyGlobally

Affects 10,000 a yearAffects 10,000 a year

Age group-16-30 yearsAge group-16-30 years

Male: female=4:1Male: female=4:1

Automobile accidents are the most Automobile accidents are the most common cause in person <65 yearscommon cause in person <65 years

Falls are the most common cause in Falls are the most common cause in person>65yearsperson>65years


TanzaniaTanzania

In TZ the research done at BMC 2012 showed In TZ the research done at BMC 2012 showed that among the SI resulted from road traffic that among the SI resulted from road traffic crashes most of them were caused by Motorcycle crashes most of them were caused by Motorcycle (58.8%) .(58.8%) .

Spine injuries was 0.7% out of all Injuries.Spine injuries was 0.7% out of all Injuries.

Male to female ratio was of 2.1:1 Male to female ratio was of 2.1:1

The modal age group was 21-30 years, The modal age group was 21-30 years, accounting for 52.1% patients.accounting for 52.1% patients.

Students (58.8%) and businessmen (35.9%) . Students (58.8%) and businessmen (35.9%) . Mortality rate was 17.5%.Mortality rate was 17.5%.


Basic Anatomy of the SpineBasic Anatomy of the Spine

1.Structure:1.Structure:Extends from the skull to the tip of theExtends from the skull to the tip of the coccyx, consisting of 33 vertebrae:coccyx, consisting of 33 vertebrae:Cervical(7), Thoracic(12), Lumbar(5), Cervical(7), Thoracic(12), Lumbar(5), Sacral(5) and Coccygeal(4)Sacral(5) and Coccygeal(4)Has 4 curvatures: cervical and lumbar Has 4 curvatures: cervical and lumbar (concave anteriorly), thoracic and sacral (concave anteriorly), thoracic and sacral (concave posteriorly)(concave posteriorly)



StructureStructure of a Typicalof a Typical VertebraVertebra

Vertebral bodyVertebral bodyEpiphyseal ring and central cancellous boneEpiphyseal ring and central cancellous bone

Neural archNeural arch2 pedicles and 2 laminae2 pedicles and 2 laminae

7 Processes7 ProcessesA spinousA spinous2 transverse2 transverse2 superior articular2 superior articular2 inferior articular2 inferior articular

Vertebral foramen & canalVertebral foramen & canal04/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 99


Atlas (C1)Atlas (C1)


Axis (C2)Axis (C2)


Lumbar VertebraLumbar VertebraSuperior viewSuperior view

..


Lumbar VertebraLumbar VertebraLateral viewLateral view

..


Thoracic VertebraThoracic VertebraLateral viewLateral view

..


2.Articulation:2.Articulation:

The entire vertebral column has similar The entire vertebral column has similar articulation (except atlanto-axial joint).articulation (except atlanto-axial joint).

The The v e r t e b r a l bodies are primarily joi n v e r t e b r a l bodies are primarily joi n e d by e d by intervertebral discs.intervertebral discs.

Anteriorly, the vertebral bodies are Anteriorly, the vertebral bodies are connected to one another by a long, strap-connected to one another by a long, strap-like, anterior longitudinal ligament, like, anterior longitudinal ligament,

Posteriorly by a similar posterior Posteriorly by a similar posterior longitudinal ligament.longitudinal ligament.


Accessory Ligaments of theAccessory Ligaments of the Intervertebral JointsIntervertebral Joints

Ligamentum flavumLigamentum flavumBetween lamina of adjacent vertebraeBetween lamina of adjacent vertebrae

SupraspinousSupraspinousBetween tips of spinous processesBetween tips of spinous processes

InterspinousInterspinousConnects adjacent spinous processesConnects adjacent spinous processes

NuchalNuchalOccipital protuberance and foramen magnum to cervical vertebraeOccipital protuberance and foramen magnum to cervical vertebrae

Intertransverse Intertransverse Connects adjacent transverse processesConnects adjacent transverse processes

NB:NB:These ligaments are together often termed the These ligaments are together often termed the posterior ligament posterior ligament complexcomplex..


Saggittal Section Thru 2 VertebraeSaggittal Section Thru 2 Vertebrae..


Three-column conceptThree-column concept

The The anterior anterior column column consists of the consists of the anterior longitudinal ligament and the anterior longitudinal ligament and the anterior part of annulus fibrosus along with anterior part of annulus fibrosus along with the anterior half of the vertebral body.the anterior half of the vertebral body.

The The middle middle column column consists of the consists of the posterior longitudinal ligament and the posterior longitudinal ligament and the posterior part of the annulus fibrosus along posterior part of the annulus fibrosus along with the posterior half of the vertebral with the posterior half of the vertebral body. body.


a) Anterior columna) Anterior column

b) Middle columnb) Middle column

c) Posterior columnc) Posterior column


The The posteriorposterior column consists of the column consists of the posterior bony arches along with the posterior bony arches along with the posterior ligament complex.posterior ligament complex.


Joints of the vertebral bodiesJoints of the vertebral bodiesIntervertebral discs which consist of annulus fibrosus and nucleus pulposusIntervertebral discs which consist of annulus fibrosus and nucleus pulposus

Anterior and posterior longitudinal ligamentsAnterior and posterior longitudinal ligaments

Joints of the neural archesJoints of the neural arches Atlantoaxial jointsAtlantoaxial joints Atlanto-occipital jointsAtlanto-occipital joints Costovertebral jointsCostovertebral joints Sacroiliac jointsSacroiliac joints


Simple General ClassificationSimple General ClassificationBased on 3 Column conceptBased on 3 Column conceptStable fracturesStable fractures

Is one where further displacement between two Is one where further displacement between two vetebral bodies does not occur because of the vetebral bodies does not occur because of the intact 'mechanical linkages'.intact 'mechanical linkages'.

When only one column is disrupted (e.g., a When only one column is disrupted (e.g., a wedge compression fracture of t h e vertebra) wedge compression fracture of t h e vertebra) the spine is stable.the spine is stable. Posterior ligament complex, neural arch and Posterior ligament complex, neural arch and articular facets intact; only vertebral bodies and articular facets intact; only vertebral bodies and anterior ligament complexanterior ligament complex04/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 2323

Unstable fracturesUnstable fractures

Is one where further displacement can occur b e c a Is one where further displacement can occur b e c a u s e of serious disruption of the structures u s e of serious disruption of the structures responsible for stability.responsible for stability.

When two columns are disrupted (e.g., a burst When two columns are disrupted (e.g., a burst fracture of the body of the vertebra) the spine is fracture of the body of the vertebra) the spine is considered u n s t a b l e .considered u n s t a b l e .

When all the t h r e e columns are disrupted, the When all the t h r e e columns are disrupted, the spine is always unstable (e.g., spine is always unstable (e.g., dislocation of one vertebra dislocation of one vertebra over other).over other).


3.Spinal cord3.Spinal cord


Dorsal root – sensory fibresDorsal root – sensory fibres

Ventral root – motor fibresVentral root – motor fibres

Dorsal and ventral roots join at Dorsal and ventral roots join at intervertebral foramen to form the spinal intervertebral foramen to form the spinal nerve nerve



Physiology and functionPhysiology and function

Grey matter – sensory and motor nerve Grey matter – sensory and motor nerve cellscells

White matter – ascending and descending White matter – ascending and descending tracts tracts

Divided into - dorsalDivided into - dorsal

- lateral - lateral

- ventral- ventral



Ascending and descending Ascending and descending pathwayspathways

Connection between cerebrum and body Connection between cerebrum and body (muscle, sensation)(muscle, sensation)Corticospinal/pyramidal tractCorticospinal/pyramidal tract = voluntary = voluntary movement movement Dorsal columnsDorsal columns = vibration, proprioception and = vibration, proprioception and fine touch fine touch Lateral spinothalamicLateral spinothalamic = pain and temperature = pain and temperature Anterior spinothalamicAnterior spinothalamic = pressure and crude = pressure and crude touch touch



Dermatomes Dermatomes

Area of skin innervated by sensory axons Area of skin innervated by sensory axons within a particular segmental nerve rootwithin a particular segmental nerve root

Knowledge is essential in determining Knowledge is essential in determining level of injurylevel of injury

Useful in assessing improvement or Useful in assessing improvement or deterioration deterioration


Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)

© 2007 Elsevier


Myotomes : Myotomes :

Segmental nerve root innervating a muscleSegmental nerve root innervating a muscleAgain important in determining level of injuryAgain important in determining level of injury

Upper limbs:Upper limbs:

CC5 5 - Deltoid - Deltoid

CC 6 6 - Wrist extensors - Wrist extensors

CC 7 7 - Elbow extensors - Elbow extensors

CC 8 8 - Long finger flexors - Long finger flexors

T T 1 1 - Small hand muscles- Small hand muscles


Lower Limbs : Lower Limbs :

LL2 2 - Hip flexors - Hip flexors

LL3,4 3,4 - Knee extensors - Knee extensors

LL4,5 4,5 – S– S1 1 - Knee flexion - Knee flexion

LL5 5 - Ankle dorsiflexion - Ankle dorsiflexion

SS1 1 - Ankle plantar flexion - Ankle plantar flexion


Denis ClassificationDenis ClassificationBased on 3 Column ConceptBased on 3 Column Concept1.1. Anterior column; ant. Long. Ligament, ant ½ of annulus Anterior column; ant. Long. Ligament, ant ½ of annulus

and vertebral bodyand vertebral body

2.2. Middle column; post. Long. Ligament and post ½ of Middle column; post. Long. Ligament and post ½ of annulus and vertebral body annulus and vertebral body

3.3. Posterior column; spinous processes, facet joints and Posterior column; spinous processes, facet joints and capsule, supra and inter spinous ligamentscapsule, supra and inter spinous ligaments


Basic Types of Spine Fractures Basic Types of Spine Fractures and their Mechanismsand their Mechanisms

1• Flexion-injury1• Flexion-injury

2• Flexion-rotation injury2• Flexion-rotation injury

3• Vertical compression injury3• Vertical compression injury

4• Extension injury4• Extension injury

5• Flexion-distraction injury5• Flexion-distraction injury

6• Direct injury6• Direct injury

7• Indirect injury due to violent muscle 7• Indirect injury due to violent muscle contractioncontraction


1.1. Flexion injury Flexion injury

This is the This is the commonest commonest spinal spinal injury.injury.

Examples:Examples:

(i) heavy blow across (i) heavy blow across the shoulder by a the shoulder by a heavy objectheavy object

(ii) fall from height on (ii) fall from height on the heels or buttocksthe heels or buttocks


ResultsResults

In the cervical spine, a flexion force can In the cervical spine, a flexion force can result in:result in:

(i) a sprain of the ligaments and muscles(i) a sprain of the ligaments and muscles

of t he back of t he neck: of t he back of t he neck:

(ii) (ii) compressioncompression fracture of fracture of

the vertebral body, C5 to C7the vertebral body, C5 to C7

(iii) dislocation of one vertebra over another (iii) dislocation of one vertebra over another (commonest C5 over C6).(commonest C5 over C6).


In the dorso-lumbar spine, this force can In the dorso-lumbar spine, this force can result in result in

The wedge compression of a vertebra The wedge compression of a vertebra (L1commonest followed by L2 and T12). (L1commonest followed by L2 and T12).

It is a It is a stable stable injury if compression of t he injury if compression of t he vertebra is less than 50 per cent of its vertebra is less than 50 per cent of its posterior height.posterior height.


2. Flexion-rotation injury:2. Flexion-rotation injury:

This is the This is the worst worst type of type of spinal injury because it spinal injury because it leaves a highly leaves a highly unstable unstable spine, and is associated spine, and is associated with high incidence of with high incidence of neurological damage.neurological damage.

Examples:Examples:

(i) heavy blow onto one (i) heavy blow onto one shoulder causing the shoulder causing the trunk to be in flexion trunk to be in flexion and rotation to theand rotation to the


opposite side (ii) a blow or fall on posterolateralaspect of the head.

ResultsResults

In the cervical spine this force can resultIn the cervical spine this force can result(i)(i) dislocationdislocation of the facet joints on one or both sides of the facet joints on one or both sides

(ii)(ii)(ii) (ii) fracture-dislocationfracture-dislocation of the cervical of the cervical

vertebra. vertebra. In the dorso-lumbar spineIn the dorso-lumbar spine

A A fracture-dislocationfracture-dislocation of the spine. of the spine.

Here one vertebra is twisted-off in front of the one Here one vertebra is twisted-off in front of the one below it. There i s extensive damage to the neural below it. There i s extensive damage to the neural arch and posterior ligament complex. It is a highly arch and posterior ligament complex. It is a highly unstable unstable injury.injury.


3.3. Vertical compression injury Vertical compression injury

It is a common spinal It is a common spinal injury.injury.

Examples: Examples:

(i)(i) A blow on the top of A blow on the top of the head by some the head by some object falling on the object falling on the headhead

(ii) a fall from height in(ii) a fall from height in

erect positionerect position


RESULTSRESULTS

In the cervical spine, this force results inIn the cervical spine, this force results in

A A burst fractureburst fracture i.e., the vertebral body is i.e., the vertebral body is crushed throughout its vertical dimensions. A crushed throughout its vertical dimensions. A piece of bone or disc may get displaced into the piece of bone or disc may get displaced into the spinal canal causing pressure on the cord.spinal canal causing pressure on the cord.

In the dorso-lumbarIn the dorso-lumbar

spine, this force results in a fracture similar to spine, this force results in a fracture similar to that in the cervical spine, but due to a wide canal that in the cervical spine, but due to a wide canal at this level, neurological deficit rarely occurs. It at this level, neurological deficit rarely occurs. It is an is an unstable unstable injury.injury.


Extension injury:Extension injury:

This injury is commonly This injury is commonly seen in the cervical seen in the cervical spine.spine.

Examples: Examples:

(i)(i) motor vehicle accident motor vehicle accident — the forehead striking — the forehead striking against the windscreen against the windscreen forcing the neck into forcing the neck into hyperextensionhyperextension

(ii) shallow water diving(ii) shallow water diving—the—the

head hitting the ground, head hitting the ground, extending the neck extending the neck

Results: Results: This injury results This injury results in a hip fracture ofin a hip fracture of

the anterior rim of a the anterior rim of a vertebra. Sometimes, thesevertebra. Sometimes, these

injuries injuries may be unstable.may be unstable.



4.4. Flexion-distraction injury: Flexion-distraction injury:

This is a recently described spinal injury, This is a recently described spinal injury, being recognised in Western countries being recognised in Western countries where use of a seat belt is compulsory while where use of a seat belt is compulsory while driving a car (chance fracture)driving a car (chance fracture)

Example:Example:

With the sudden stopping of a car, theWith the sudden stopping of a car, the

upper part of t h e body is forced forward by upper part of t h e body is forced forward by inertia while the lower part is tied to inertia while the lower part is tied to

the seat by the seatbelt. the seat by the seatbelt. 04/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 4747


5.5. Direct injury Direct injury

This is a rare type of This is a rare type of spinal injury.spinal injury.

Examples:Examples:

(i) bullet injury; (ii) a (i) bullet injury; (ii) a lathi lathi blow hitting the blow hitting the spinous processes of spinous processes of the cervical vertebrae.the cervical vertebrae.

Results:Results:

Any part of the Any part of the vertebra may be vertebra may be smashed by a bullet, smashed by a bullet, but, a lathi blow but, a lathi blow generally causes a generally causes a fracture of t he fracture of t he spinous processes spinous processes only.only.


6.Violent muscle contraction6.Violent muscle contraction

This is a rare injury.This is a rare injury.

Example: Example: Sudden Sudden violent contraction of violent contraction of the psoas.the psoas.

Results: Results: It results in It results in fractures of the fractures of the transverse processes transverse processes of multiple lumbar of multiple lumbar vertebrae.vertebrae.

It may be It may be a s s o c i a a s s o c i a t e d with a huge t e d with a huge retroperitoneal retroperitoneal haematoma.haematoma.


Spinal Column InjurySpinal Column Injury1.1. Cervical Spine Injuries Cervical Spine Injuries

–Fall from Fall from heightheight

–Diving Diving accidentaccident

–Whiplash Whiplash injuryinjury

MechanismMechanism

FlexionFlexion Flexion and Flexion and

rotationrotation ExtensionExtension CompressionCompression


Causes:Causes:

Occipito – Atlantal DislocationOccipito – Atlantal Dislocation

Fatal Fatal

Subluxation without ND may surviveSubluxation without ND may survive

Early & correct diagnosis with CT scan or Early & correct diagnosis with CT scan or MRIMRI

Dx by lateral cervical radiographDx by lateral cervical radiograph

Tip of odontoid from basion: Alignment Tip of odontoid from basion: Alignment <5mm vertically & <1mm horizontally<5mm vertically & <1mm horizontally


OAD OAD ImagingImaging


OAD OAD ImagingImaging


OAD OAD TreatmentTreatment

Initially by halo immobilisation without Initially by halo immobilisation without tractiontraction

Definitive: posterior occipito – cervical Definitive: posterior occipito – cervical fusionfusion



Atlas (C1) fracturesAtlas (C1) fractures

Described as Jefferson #Described as Jefferson #Axial load Axial load Usually no neurological Usually no neurological deficitdeficit1/3 have C2 #1/3 have C2 #Usually stableUsually stable


C1 fracture – C1 fracture – TreatmentTreatment

Lateral massesLateral masses– Undisplaced stable #s: Undisplaced stable #s:

semi rigid collar or halo – semi rigid collar or halo – vest until it unitesvest until it unites

– Displaced: side ways Displaced: side ways spreading > 7mm; unstable spreading > 7mm; unstable & may require posterior & may require posterior C1/2 arthrodesisC1/2 arthrodesis



Axis (C2) #Axis (C2) #Includes Hangman’s # Includes Hangman’s # and Odontoid process #and Odontoid process #

HANGMAN’S #HANGMAN’S #Bilateral # of the isthmus Bilateral # of the isthmus of the pedicles of C2 with of the pedicles of C2 with anterior sublaxation of anterior sublaxation of C2-C3C2-C3Hyperextention and axial Hyperextention and axial loadingloadingUsually stableUsually stable


Spinal Column InjurySpinal Column InjuryAxis (C2) #Axis (C2) #

Includes Hangman’s Includes Hangman’s # and Odontoid # and Odontoid process #process #

Odontoid #Odontoid #Flexion injuryFlexion injury15% of all cervical 15% of all cervical injuriesinjuriesII unstable,I & III II unstable,I & III stablestable

I

II

III


Odontoid Fracture (C2)Odontoid Fracture (C2)

Anderson & D’Alonzo Anderson & D’Alonzo classification:classification:

Type 1Type 1 – An avulsion – An avulsion fracture of tip of odontoid fracture of tip of odontoid process due to traction of process due to traction of alar lig.alar lig.Type 2Type 2 – # at the junction – # at the junction of odontoid process and of odontoid process and the body. Most common the body. Most common & potentially dangerous & potentially dangerous typetypeType 3Type 3 – # thru the body – # thru the body of axisof axis


Odontoid Fracture Cont’dOdontoid Fracture Cont’d

TreatmentTreatment

Type 1 – Type 1 – Mobilise in rigid Mobilise in rigid collar 8-12 wks collar 8-12 wks

Type 2 Type 2 – Undisplaced #s:Undisplaced #s: halo – halo –

vest for 8-12 wks vest for 8-12 wks – Displaced : Skull traction Displaced : Skull traction

then wiring or screw then wiring or screw fixation fixation

Type 3 – Traction or halo-Type 3 – Traction or halo-vest depending on vest depending on whether displaced or notwhether displaced or not


Spinal Column InjurySpinal Column InjurySubaxial (C3-C7) #Subaxial (C3-C7) #

Whiplash injury:Whiplash injury: Traumatic injury to the Traumatic injury to the

soft tissue in the cervical soft tissue in the cervical regionregion

Hyperflexion, Hyperflexion, hyperextentionhyperextention

No fractures or No fractures or dislocationsdislocations

Most common automobile Most common automobile injuryinjury

Recover 3-6 monthsRecover 3-6 months


Whiplash InjuryWhiplash Injury

X ray: loss of cervical lordosis due to muscle X ray: loss of cervical lordosis due to muscle spasmspasmMRI: disc herniationMRI: disc herniationCervical collar and graded exercisesCervical collar and graded exercises



Vertical compression Vertical compression injury:injury:

Loss of normal cervical Loss of normal cervical lordosislordosis

Burst #Burst # Compression of spinal Compression of spinal

cordcord UnstableUnstable Requires decompression Requires decompression

and fusionand fusion



Compression flexion Compression flexion injury (teardrop #)injury (teardrop #)

Classical diving injuryClassical diving injury Posterior elements Posterior elements

involved in >50%involved in >50% Displacement of inferior Displacement of inferior

margin of the bodymargin of the body UnstableUnstable Requires stabilizationRequires stabilization



flexion distraction injury flexion distraction injury (locked facet)(locked facet)

>50% displacement>50% displacement UnstableUnstable Requires reduction and Requires reduction and

stabilizationstabilization



extention injury (# extention injury (# posterior elements)posterior elements)

# lamina, pedicles or # lamina, pedicles or spinous processspinous process

With or without With or without ligamentous injuryligamentous injury

Usually stableUsually stable


Clay Shoveller’s InjuryClay Shoveller’s Injury

Fracture of C7 spinous process with Fracture of C7 spinous process with severe voluntary contraction of back severe voluntary contraction of back muslcesmuslces

Painful but harmlessPainful but harmless

Only analgesiaOnly analgesia


Spinal Column InjurySpinal Column InjuryThoracic and lumbar #Thoracic and lumbar #

Stability (three column Stability (three column model of Denis)model of Denis)

Injury affecting two or Injury affecting two or more column is unstablemore column is unstable


Spinal Column InjurySpinal Column InjuryThoracic and lumbar #Thoracic and lumbar #

Compression #Compression #Burst #Burst #Chance # (seat belt)Chance # (seat belt)Flexion distractionFlexion distractionFracture dislocationFracture dislocation


WedgeWedge Compression FractureCompression Fracture

Stable injury affecting Stable injury affecting only ant. column only ant. column

Semi – rigid collar Semi – rigid collar


Posterior Lig. InjuryPosterior Lig. Injury

Sudden flexion of mid cervical spineSudden flexion of mid cervical spine

Damage to post. lig. ComplexDamage to post. lig. Complex

Upper vertebra tilts forward on one below Upper vertebra tilts forward on one below & opening interspinous space& opening interspinous space


Posterior Lig. Injury Cont’dPosterior Lig. Injury Cont’d

Treatment Treatment

Unstable: Unstable: – Angulation of VB with its neighbour >11Angulation of VB with its neighbour >11ºº

– Anterior translation of a vertebra >3.5mmAnterior translation of a vertebra >3.5mm– # or dislocation of facet# or dislocation of facet

Treated with post. fixation & fusionTreated with post. fixation & fusion

Stable Stable – Semi – rigid collar x 6wksSemi – rigid collar x 6wks


Burst FractureBurst Fracture

Axial loading as in diving Axial loading as in diving or athletic accidents or athletic accidents

Comminuted fracture of Comminuted fracture of vertebral bodyvertebral body

Frag. may enter spinal Frag. may enter spinal canalcanal

Halo vest or anterior Halo vest or anterior decompression if decompression if neurological deficit neurological deficit present & immobilisation present & immobilisation x 6-8 wksx 6-8 wks


Cervical Disc HerniationCervical Disc Herniation

Severe pain radiating upper limbsSevere pain radiating upper limbs

Paresthesia and weakness may be Paresthesia and weakness may be presentpresent

If there is paresis, then decompression is If there is paresis, then decompression is indicated – ant discectomy & interbody indicated – ant discectomy & interbody fusionfusion


Signs and symptomsSigns and symptoms

The extent of injury is defined by the American The extent of injury is defined by the American Spinal Injury Association (Spinal Injury Association (ASIAASIA) Impairment ) Impairment Scale (modified from the Frankel classification), Scale (modified from the Frankel classification), using the following categoriesusing the following categories..

A – Complete: no sensory or motor function A – Complete: no sensory or motor function preserved in sacral segments Spreserved in sacral segments S4 4 – S– S55

B – Incomplete: sensory, but no motor function in B – Incomplete: sensory, but no motor function in sacral segmentssacral segments


C – Incomplete: motor function preserved C – Incomplete: motor function preserved below level and power graded < 3below level and power graded < 3

D – Incomplete: motor function preserved D – Incomplete: motor function preserved below level and power graded 3 or morebelow level and power graded 3 or more

E – Normal: sensory and motor function E – Normal: sensory and motor function normalnormal

Spinal Shock vs Neurogenic ShockSpinal Shock vs Neurogenic Shock

Spinal Shock :Spinal Shock : Transient reflex depression of cord function below level Transient reflex depression of cord function below level

of injuryof injury Initially hypertension due to release of catecholaminesInitially hypertension due to release of catecholamines Followed by hypotensionFollowed by hypotension Flaccid paralysis Flaccid paralysis Bowel and bladder involvedBowel and bladder involved Sometimes priaprism develops Sometimes priaprism develops Symptoms last several hours to days Symptoms last several hours to days

Neurogenic shock: Neurogenic shock: Triad of i) hypotensionTriad of i) hypotension

ii) bradycardia ii) bradycardia

iii) hypothermiaiii) hypothermiaMore commonly in injuries above TMore commonly in injuries above T6 6

SecondarySecondary to disruption of sympathetic to disruption of sympathetic outflow from Toutflow from T1 1 – L– L2 2

Loss of vasomotor tone – pooling of bloodLoss of vasomotor tone – pooling of blood

Loss of cardiac sympathetic tone – bradycardia Loss of cardiac sympathetic tone – bradycardia

Blood pressure will not be restored by fluid Blood pressure will not be restored by fluid infusion aloneinfusion alone

Massive fluid administration may lead to Massive fluid administration may lead to overload and pulmonary edema overload and pulmonary edema

Vasopressors may be indicatedVasopressors may be indicated

Atropine used to treat bradycardia Atropine used to treat bradycardia

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


Types of incomplete injuriesTypes of incomplete injuries

i)i) Central Cord SyndromeCentral Cord Syndrome

ii)ii) Anterior Cord SyndromeAnterior Cord Syndrome

iii)iii) Posterior Cord SyndromePosterior Cord Syndrome

iv)iv) Brown – Sequard SyndromeBrown – Sequard Syndrome

v)v) Cauda Equina SyndromeCauda Equina Syndrome

i)i) Central Cord Syndrome :Central Cord Syndrome :

Typically in older patientsTypically in older patients Hyperextension injuryHyperextension injury Compression of the cord anteriorly by Compression of the cord anteriorly by

osteophytes and posteriorly by osteophytes and posteriorly by ligamentum flavumligamentum flavum

Also associated with fracture dislocation Also associated with fracture dislocation and compression fracturesand compression fractures

More centrally situated cervical tracts tend More centrally situated cervical tracts tend to be more involved to be more involved hencehence

flaccid weakness of arms > legs flaccid weakness of arms > legs

Perianal sensation & some lower extremity Perianal sensation & some lower extremity movement and sensation may be movement and sensation may be preserved preserved

ii) Anterior cord Syndrome:ii) Anterior cord Syndrome: Due to flexion / rotationDue to flexion / rotationAnterior dislocation / compression fracture Anterior dislocation / compression fracture

of a vertebral body encroaching the ventral of a vertebral body encroaching the ventral canalcanal

Corticospinal and spinothalamic tracts Corticospinal and spinothalamic tracts are damaged either by direct trauma or are damaged either by direct trauma or ischemia of blood supply (anterior spinal ischemia of blood supply (anterior spinal arteries) arteries)

Clinically:Clinically: Loss of powerLoss of powerDecrease in pain and sensation below Decrease in pain and sensation below

lesionlesionDorsal columns remain intactDorsal columns remain intact

ii) Posterior Cord Syndrome: ii) Posterior Cord Syndrome:

Hyperextension injuries with fractures Hyperextension injuries with fractures of of the posterior elements of the vertebrae the posterior elements of the vertebrae

Clinically: Clinically: Proprioception affected – ataxia and Proprioception affected – ataxia and

faltering gait faltering gait Usually good power and sensationUsually good power and sensation

ii) Posterior Cord Syndrome: ii) Posterior Cord Syndrome:

Hyperextension injuries with fractures Hyperextension injuries with fractures of of the posterior elements of the vertebrae the posterior elements of the vertebrae

Clinically: Clinically: Proprioception affected – ataxia and Proprioception affected – ataxia and

faltering gait faltering gait Usually good power and sensationUsually good power and sensation

iv) Brown – Sequard Syndromeiv) Brown – Sequard Syndrome: : Hemi-section of the cordHemi-section of the cordEither due to penetrating injuries:Either due to penetrating injuries:

i) stab woundsi) stab wounds

ii) gunshot woundsii) gunshot woundsFractures of lateral mass of vertebrae Fractures of lateral mass of vertebrae

Clinically: Clinically: ParalysisParalysis on affected side (corticospinal)on affected side (corticospinal)Loss of proprioception and fine Loss of proprioception and fine

discrimination (dorsal columns)discrimination (dorsal columns)Pain and temperature loss on the Pain and temperature loss on the opposite opposite

side below the lesion side below the lesion (spinothalamic)(spinothalamic)

v) Cauda Equina Syndromev) Cauda Equina Syndrome:: Due to bony compression or disc Due to bony compression or disc

protrusions protrusions in lumbar or sacral regionin lumbar or sacral region

Clinically Clinically Non specific symptoms – back painNon specific symptoms – back pain

- bowel and bladder dysfunction- bowel and bladder dysfunction- leg numbness and weakness- leg numbness and weakness- saddle parasthesia - saddle parasthesia

INVESTIGATIONSINVESTIGATIONS

Good ante-posterior and lateral X-rays Good ante-posterior and lateral X-rays centring centring on the involved segment provide on the involved segment provide reasonable information about the injury.reasonable information about the injury.

Sometimes, special imaging techniques Sometimes, special imaging techniques are required e.g., Tomogram, C.T. scan, are required e.g., Tomogram, C.T. scan, M.R.I,M.R.I,


Plain X-rays: Plain X-rays:

(i) confirmation of diagnosis(i) confirmation of diagnosis

(ii) assessment of mechanism of injury and(ii) assessment of mechanism of injury and

(iii) assessment of the stability of the spine.(iii) assessment of the stability of the spine.

The following features may be noted on plain XraysThe following features may be noted on plain Xrays

• • Change in the general alignment of the spineChange in the general alignment of the spine

i.e., antero-posterior bending (kyphosis) or sideways bending i.e., antero-posterior bending (kyphosis) or sideways bending (scoliosis).(scoliosis).

• • Reduction in t h e height of a vertebra.Reduction in t h e height of a vertebra.

• • Antero-posterior or sideways displacement of one vertebra over Antero-posterior or sideways displacement of one vertebra over another.another.

• • Fracture of a vertebral body. • Fracture of t h e posterior elements Fracture of a vertebral body. • Fracture of t h e posterior elements i.e., pedicle, lamina, transverse processi.e., pedicle, lamina, transverse process


C.T. C.T. scan and scan and M.R.IM.R.I

C.T. scan h a s proved to be a very helpful C.T. scan h a s proved to be a very helpful investigation. One can see the damaged investigation. One can see the damaged structures more clearly, and make note of structures more clearly, and make note of any bony fragment in the canal. any bony fragment in the canal.

M.R.I. is the best modality of imaging an M.R.I. is the best modality of imaging an injured spine.injured spine.

In addition to showing better, the details In addition to showing better, the details of injured bones and soft-tissues,it shows of injured bones and soft-tissues,it shows very well the anatomy of t he cord.very well the anatomy of t he cord.


Tomogram: Tomogram:

A tomogram helps in better delineation of A tomogram helps in better delineation of a doubtful area. Myelogram has no role in a doubtful area. Myelogram has no role in the management of acute spinal injuries.the management of acute spinal injuries.


MANAGEMENTMANAGEMENT


The treatment of spinal injuries can be The treatment of spinal injuries can be divided into three phases, as in other divided into three phases, as in other injuries:injuries:

Phase I: Phase I: Emergency care at the Emergency care at the scene of scene of accident accident or in emergency department.or in emergency department.

Phase II: Phase II: Definitive care in Definitive care in emergency emergency department or in the ward.department or in the ward.

Phase III: Phase III: RehabilitationRehabilitation


Phase I - Phase I - At the scene of accidentAt the scene of accident

An An acute pain acute pain in the back following an injury is to in the back following an injury is to be considered a spinal injury unless proved be considered a spinal injury unless proved otherwise.otherwise.

Also, all suspected spinal injuries are to be Also, all suspected spinal injuries are to be considered unstable unless considered unstable unless their stability is their stability is confirmed on s u b s e q u e n t confirmed on s u b s e q u e n t investigation. investigation.

NB: NB: A patient with a spinal injury has to be given A patient with a spinal injury has to be given the utmost care right at the scene of accident; the utmost care right at the scene of accident; the basic principle being to the basic principle being to avoid any movement avoid any movement at the injured segment.at the injured segment.


While moving a person with a suspected cervicalWhile moving a person with a suspected cervical

spine injury, one person should hold the neck inspine injury, one person should hold the neck in

traction by keeping the head pulled. traction by keeping the head pulled. The rest of the body is supported at the The rest of the body is supported at the

shoulder, pelvis and legs by three other people. shoulder, pelvis and legs by three other people. Whenever required, the whole body is to be Whenever required, the whole body is to be moved in one piece so t h a t no movement moved in one piece so t h a t no movement occurs at the spine.occurs at the spine.

The same precaution is observed in a case with The same precaution is observed in a case with suspected dorso-lumbar injury.suspected dorso-lumbar injury.


In the emergency departmentIn the emergency department

The patient should not be moved from the The patient should not be moved from the trolley on which he is first received until trolley on which he is first received until stability of t he spine is confirmedstability of t he spine is confirmed

A quick general examination of t h e A quick general examination of t h e patient is carried out in order to detect any patient is carried out in order to detect any other associated injuries to the chest,other associated injuries to the chest, abdomen, pelvis, limbs etc.abdomen, pelvis, limbs etc.

The spine i s examined for any The spine i s examined for any tenderness, crepitus or haematoma.tenderness, crepitus or haematoma.


PHASE II - DEFINITIVE CAREPHASE II - DEFINITIVE CARE

Definitive care of a patient with spinal injury Definitive care of a patient with spinal injury depends upon the stability of the spine and the depends upon the stability of the spine and the presence of a neurological deficit.presence of a neurological deficit.

The aim of treatment is:The aim of treatment is:

(i) to avoid any deterioration of the neurological (i) to avoid any deterioration of the neurological status;status;

(ii) to achieve stability of the spine by conservative or (ii) to achieve stability of the spine by conservative or operative methodsoperative methods

(iii) to rehabilitate the paralysed patient to the best (iii) to rehabilitate the paralysed patient to the best possible extent. possible extent.


Treatment of cervical spine Treatment of cervical spine injuriesinjuries

Cervical spine injuries are often associated with Cervical spine injuries are often associated with head injuries, the effect of which may mask the head injuries, the effect of which may mask the spinal lesion. spinal lesion.

Therefore, it is necessary to get an X-ray of the Therefore, it is necessary to get an X-ray of the cervical spine in any serious case of head injury. cervical spine in any serious case of head injury.

The aim of treatment is to achieve proper The aim of treatment is to achieve proper alignment of vertebrae, and maintain it in that alignment of vertebrae, and maintain it in that position till the vertebral column stabilises.position till the vertebral column stabilises.

This can be achieved in most cases by This can be achieved in most cases by conservative methods. In some cases, an conservative methods. In some cases, an operation operation may be required for-reducing or stabilising the spine.may be required for-reducing or stabilising the spine.


ReductionReduction

is achieved by skull traction applied is achieved by skull traction applied through skull calipers—through skull calipers—Crutchfield tongsCrutchfield tongs

A weight of up to 10 kg is applied and A weight of up to 10 kg is applied and check X-rays taken every 12 hourscheck X-rays taken every 12 hours



Operation: Operation:

This may be required for:This may be required for:

(i) irreducible subluxation because of (i) irreducible subluxation because of 'locking' of the articular processes or'locking' of the articular processes or

(ii) persistent instability.(ii) persistent instability.

The operationThe operation consists of inter-body fusion consists of inter-body fusion (anterior fusion) or fusion of the spinous (anterior fusion) or fusion of the spinous processes and laminae (posterior fusion). processes and laminae (posterior fusion).

Internal fixation may be required.Internal fixation may be required.04/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 111111

Treatment of thoracic and Treatment of thoracic and lumbar spine injurieslumbar spine injuries

Operative methods:Operative methods:

Whenever necessary the following Whenever necessary the following operative methods are performed operative methods are performed

• • Harrington instrumentation — bilateral.Harrington instrumentation — bilateral.

• • Luque instrumentation.Luque instrumentation.

• • Hartshill rectangle fixation.Hartshill rectangle fixation.

• • Pedicle screw fixation.Pedicle screw fixation.04/11/2304/11/23 MSIGWA SAM-MD5MSIGWA SAM-MD5 112112

References: References: 1.1. Andrew T Raftery, et al. Applied Basic Science for Andrew T Raftery, et al. Applied Basic Science for

Basic Surgical Training. Second edition 2008;8:219-Basic Surgical Training. Second edition 2008;8:219-223223

2.2. Essential Orthopaedics 3Essential Orthopaedics 3rdrd EDITION-Maheshwari EDITION-Maheshwari3.3. Handbook of Fractures 3Handbook of Fractures 3rdrd Edition Edition4.4. Dr.Ferdinand Massaga-UDOM,classnotesDr.Ferdinand Massaga-UDOM,classnotes5.5. Spinal cord injuries-JC KingSpinal cord injuries-JC King6.6. Muhas presentationMuhas presentation

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