Evaluation of the Traumatic Spine Naftaly Attias, MD Orthopedic Department St Josephs HMC - Phoenix, AZ

Emergency Room Thorough, documented initial neurological examination In the first 24 hours, all care taker should do their own thorough documented evaluation Get Info about neuro status in the accident scene

Inspection & Palpation Remove all clothing Note abrasions, contusions and limb asymmetry Breathing ( paradoxical respiration, etc) Spine deformity Anteriorly: carotid pulses , tracheal deviation Posteriorly: palpate the cervical, thoracic and lumbar spine ⇒ pain, tenderness, widening or malrotation

Log rolling Necessary - should be done very carefully, as has been shown to create a potential for neuro compromise.

Physical Examination Sensory, Motor and Reflexes. Attempt to determine neurologic injury location and type ( complete/ incomplete)

Root Level. Key Muscles C3. C4. Diaphragm C5   Root Level Key Muscles   C3. C4 Diaphragm C5 Deltoid, elbow flexors, diaphragm C6 Elbow flexors, wrist extensors C7 Elbow extensors, wrist flexors C8 Finger flexors (distal phalanx of middle finger) T1 Finger abductors (5th digit), intrinsics of hand T1‑T12 Segmental innervation to intercostal muscles, abdominal and paraspinal muscles (T12) L1, L2, L3 Hip flexors L2, L3, L4 Quadriceps L4 Tibialis anterior L5 Toe extensors, hip abductors S1 Ankle plantarflexors, peronei   Reference: Kasser 3R: OKU 5, Rosemont, IL, American Academy of Orthopaedic Surgeoms, 1996, pp573‑588.

Motor exam 5. full strength adequate to powerfully resist the examiner 4. power to resist but not overcome the examiner 3. power to overcome gravity 2. power to move the joint but not to overcome gravity 1. capacity to contract the muscle without functional power 0. no motor function at all

Sensory exam Do not be limit to touch Test temperature, pain, pressure differentials, vibration This will give us some idea if this is more anterior vs. dorsal column injury.

Sensory exam Utmost importance: the innervation of S2-S5 indicates the functional status of the distal-most aspect of the spinal cord = prognosis for a functional recovery Babinski & Oppenheim reflexes are suggestive of an upper motor neuron problem

Reflexes Spinal cord injury = cerebral inhibition is lost . At first - spinal shock with hyporeflexia. Later - hyperreflexia Lower motor neuron injury = flaccid, hyporeflexia secondary to both an interruption of the nerve and the reflex arc.

Spinal shock About 24 hours bulbocavernosus reflex indicates the end of spinal shock, and then complete vs incomplete spinal cord injury can be determined

Clearing the Spine The necessary elements : History to assess for high-risk events and factors Clinical examination to check for physical signs of spinal injury or neurologic deficit. In alert asymptomatic patients, cervical spine radiography may be omitted. Need radiography if midline neck tenderness, neck pain, evidence of intoxication, abnormal level of alertness, neuro deficit, or painful injuries elsewhere.

Radiology - Plain Film AP/Lat + dense + swimer Need to see C7-T1

Radiology - CT More info Difficult areas 2D, 3D

Radiology - MRI Helpful in showing disruptions of ligaments and posterior tissues and thereby provides an indication of stability Before reduction of facet dislocation in obtunded patient or if during reduction neuro deficit

Cervical Spine Be systematic Anteriorly - look at the soft tissues Ant & post cortex (lines A & B) - look for translation or angulation Canal and facets - spinolaminar line (line C) Outline of the spinous processes (line D) – look for widening

Cervical Spine - Stability White and Punjabi defined spinal stability in terms of step-off and angular deformity on a single static lateral view Dynamic studies can be done for patients who are neurologically intact and are border-line unstable - as long as these studies are done under your direct supervision

Thoracic Spine AP / Lat Multiple rib Fx - warning sign for possible spinal injury Look carefully for rotation or translation The upper thoracic spine is especially difficult to visualize

Lumbar Spine Critical descriptors : amount of vertebral body height loss kyphosis % canal compromise translation pedicle widening interspinous process widening help define stability and appropriate treatment

NO! Pitfalls Erroneous classifications Missed associated injuries Clay shoveler's fracture??? Pitfalls Erroneous classifications Missed associated injuries Inadequate exams and films Ankylosed spine: (i.e. ankylosing spondylitis and DISH) pain = fracture until proved otherwise Sacral fractures NO! Almost complete bilateral facet dislocation

Thank You

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