Spinal injuries Principles and treatment Presented By: Fadel Naim M.D. Orthopedic Surgeon Faculty of Medicine IUG

Background Approximately half the injuries occur in the thoracic, lumbar, and sacral areas The other half occur in the cervical spine. The average age at injury is 32 years 55% of those injured are aged 16-30 years Approximately 80% of patients are male

Spinal injuries can be described as: Fractures Fracture dislocations SCIWORA / SCIWORET Penetrating injuries

All injuries can stable or unstable All patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury.

Blunt trauma Motor vehicle accidents Falls Exlopsive injuries Sport injuries

Spine injuries can result from Axial loading Flexion Extension Rotation Lateral bending Distraction

Spine Trauma suspect if Head Trauma/ Loss of cosciousness FFH # calcaneum

Initial management The goals for the emergency physician are to: Establish the diagnosis Initiate treatment Prevent further neurologic injury from either: pathologic motion of the injured vertebrae secondary injury from the deleterious effects of cardiovascular instability respiratory insufficiency.

Prehospital care: stabilize and immobilize the spine on the basis of mechanism of injury, pain in the vertebral column, or neurologic symptoms. Patients are usually transported to the ED with a cervical hard collar on a hard backboard.

ABCs & Immobilization Initial management Rigid collar/ backboard Airway/ ventilatory support Hemodynamic support

Beware Excessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome

Log rolling

Spine Trauma: Clinical : Exam Look Skin: Bruise,Wound Posture Feel Tender Swelling Bony landmarks Do NOT move !!

Initial management Neurological exam: performed as soon as the patient is hemodynamically stable: Motor Sensation DTRs digital rectal exam

If patient is conscious: radiographs and full exam spinal injury can be excludes if: No pain Normal clinical examination of spine Normal neuro exam If the patient is unconscious : spinal injury unless proven otherwise……? neuro exam…radiographs… other urgent surgeries…

Initial Assessment Motor Examination Upper extremity C5-shoulder abduction C6-wrist extension C7-wrist flexion C8-finger flexion T1-finger abduction

Initial Assessment Motor Examination Lower extremity L1-hip flexion L2-hip adduction L3-knee extension L4-ankle dorsiflexion L5-toe extension

Initial Assessment Dermatomes

Reflex Examination

Nerurogenic Shock vs Spinal Shock Neurogenic shock results from impairment of the descending sympathetic pathways in the spinal cord resulting in loss of vasomotor tone and loss of sympathetic innervation to the heart The result is: Hypotension Bradycardia

Nerurogenic Shock vs Spinal Shock Spinal Shock results immediately after severe cord injury a state of diminished excitability of the spinal cord.. Due to sudden withdrawal of a facilitating or excitatory influence from the supraspinal centers. Areflexic flaccid paralysis Hypotension Bradycardia Duration varies: avg 3-4w

Clinical evaluation Pain Neurologic symptoms/signs Image exams ASIA Frankel scale Image exams

American Spinal Injury Association (ASIA) A = Complete – No Sacral Motor / Sensory B = Incomplete – Sacral sensory sparing C = Incomplete – Motor Sparing (<3) D = Incomplete – Motor Sparing (>3) E = Normal Motor & Sensory

Frankel Scale A B C D E Sensory Motor Absent Present Active but not useful (grade 2-3) D Active and useful (grade 4) E Normal

Investigations: Imaging the spine does not take precedence over life-saving diagnostic and therapeutic procedures

Image exams Plain radiographs CT MRI Cheap and widely available 99% sensitivity for fracture Quick Disavantage – price and availability MRI Low specifity Recommended to acces for injuries to soft tissue (ligamental, intervertebral disc, spinal cord injury) Can distinguish betwen spinal cord edema and hemorrage Very expensive No better than CT as screening tool

Trauma series includes X-ray for : lateral cervical Chest lateral thoracic A/P and lateral lumbar A/P pelvis

CT Scan L3 unstable burst fracture

MRI Scan Thoracic fracture subluxation with increased signal in conus medullaris

Spinal Cord Injury w/o Radiologic Abnormality SCIWORA Spinal Cord Injury w/o Radiologic Abnormality Spinal cord stretching leads to neuronal injury or even complete severing of the cord Accounts for up to 70 % of ped. Spinal cord injuries Most common in kids < 8 years Paralysis may be present on arrival Up to 30 % have a delayed onset of neurologic abnormalities May not occur until up to 4-5 days after injury Many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved

SCIWORET Spinal cord injury without radiographic evidence of trauma First described in pediatric population (SCIWORA) In adults, tends to affect the elderly Much more prevalent in cervical spine as opposed to the thoracolumbar area. Related to the degenerative changes in the c-spine

Classifications Necessary for…… Uniform method of description Directing treatment *** Facilitating outcome analysis Should be: Comprehensive Reproducible Usable Accurate

Fracture Classification Fracture classification allows organization and treatment of fractures through protocols developed to maximize patient outcomes Most classification schemes based on criteria for describing stability The mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment

Anatomic Classification 2 or 3 Columns Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Holdsworth’62 Kelley & Whitesides ’68

Mechanical Stability 3-column theory (Denis ‘83) middle = posterior ½ VB, posterior disc, post longitudinal lig Disruption of 2/3 unstable 2-column theory (Holdsworth,’53) anterior= VB, disc, ALL, PLL posterior= neural arch, Post lig complex

Anterior - Anterior longitudinal ligament, anterior half annulus fibrosus and vertebral body. Middle - Posterior longitudinal ligament, posterior half annulus fibrosus and vertebral body. Posterior - Osseous and ligamentous structures posterior to the posterior longitudinal ligament, (Interspinous ligaments)

Spine Fracture Types Compression fractures Result from axial loading and flexion Failure of the anterior column Middle, posterior columns intact Usually stable unless > 50% height Unlikely to be directly responsible for neurologic damage

Burst Fractures Axial load Both anterior and middle columns fail Retro-pulsion of bone and disk fragments into the canal May cause spinal cord compression

Fracture Dislocations Most damaging of injuries Failure of all three columns Compression, flexion, distraction, rotation, or shearing forces

Flexion- distraction Seat belt–type injuries Particularly where lap belts alone are used Failure of both the posterior and middle columns Intact anterior column prevents subluxation Radiographic findings: Increased height of the posterior vertebral body Fracture of posterior wall of the vertebral body Posterior opening of the disk space.

Whiplash injury Sudden hyperextension and flexion Increasing neck pain for the first 24hours Associated headache, pain radiating to both shoulders and paraesthesia in hands Reduced lateral flexion Anterior longitudinal ligaments are torn causes dysphagia Forward flexion against resistance is painful 90% are asymptomatic after 2years 10% still have pain

AP & lateral view radiographs of the lumbar spine demonstrates a narrowed T12 vertebral body height consistent with a compression fracture.

CT scan. Note the large amount of bone retropulsed inside the spinal canal Lumbar spine fractures and dislocations. Plain radiographs reveal a fracture of L2 with L2-L3 subluxation.

Scout view image from a spiral CT scan shows a complete subluxation fracture (curved blue lines) of the lower thoracic spine. Such an injury combines lateral displacement with rotational injury

Treatment Non-operative Treatment Surgical Treatment Rehabilitation

Goals of Non-operative Treatment Preserve neurological function Minimize deformity progression Decrease pain Restore Function ASSUMES THE SPINE IS STABLE

Criteria No neurologic deficit Kyphotic angle of less than 25° Less than 50% compromisse of the spinal canal by the bony fragment

Non Surgical Treatment Bed rest External support Simple corsets Three-point fixation devices (Jewet) Total-contact orthoses (TLSO)

Braces and orthotics do three things: 1) maintain spinal alignment 2) immobilize spine during healing 3) control pain by restricting movement.

3 components: Surgical Treatment Neural Decompression Stabilization Patients w/progressive deficit need emergent decompression Stabilization Anterior stabilization Posterior stabilization Posterior and anterior stabilization Fusion Autograft (Iliac crest) Allograft Synthetic cage

Post-op Rehabilitation and physical therapy Early ambulation is recommended for patients who are neurologically intact or those who have limited neurologic impairment. Patients with significant neurologic impairment or those who are paraplegic should also have active recovery and early mobilization.

Post-op Rehabilitation and physical therapy Patients with significant neurologic impairment or those who are paraplegic may need to spend time at a rehabilitation facility until they have been trained to adapt and to cope with their disability The focus of rehabilitation: bowel and bladder management transfer techniques Psychological counseling Proper pain management is also important for successful rehabilitation.

Spine Trauma: Cervical C1: Jefferson C2: Hangman, odontoid, C3-C7: wedge-compression, burst, subluxation, #-dislocation Avulsion C7 spine Whiplash

Cervical Spine Injuries Atlanto- Occipital Dislocation Hyperextension and distraction mechanism Down’s syndrome, RA more susceptible Asymmetric lateral masses on odontoid view Widened pre-dens space Treatment- Often fatal Highly unstable If not fatal avoid traction, definitive fusion occiput to C1

Atlanto-axial Dislocation Hyperextension injury Children>adults Head slips forward on C1 Usually fatal

Atlas Fractures Jefferson fracture Burst fracture of atlas (C1) Usually bilateral breaks in ant/ post arches Vertical compression/ axial load injury Widened lateral masses of C1 on open-mouth odontoid view Widened pre-dens space Moderately unstable Neuro deficits uncommon Associated with: Fractures of C7 (25%) Fractures of C2 pedicle (15%) Extra-spinal fractures (58%)

Axis Fractures Incidence: 6% of cervical spine fractures Associated with atlas fractures in 8% Hyperextension Often forward subluxation of C1 on C2 Odontoid fracture Type I Avulsion of tip of odontoid (5-8%) Difficult to detect; required CT Type II Fracture through base of dens (54-67%) Complication: nonunion Type III Subdental injury (30-33%) Prognosis: good

Hangman’s Fracture Most common fracture of C2 Bilateral fracture of pedicles of axis (C2) Anterior slip of C2 on C3 Mechanism: Sudden deceleration with hyperextension May or may not have anterior subluxation Unstable Neuro deficits variable Teardrop fracture of inferior aspect of C2 or C3 is clue

Hangman

Tear Drop Fracture Avulsion of antero-inferior corner of cervical vertebral body by anterior ligament Most severe and unstable injury of the C-spine Mechanism: may be secondary to hyperflexion or hyperextension sudden, forceful flexion Often the result of diving into shallow water Typically at C2 Unstable with ligamentous instability Remainder of body displaced backward into spinal canal Facet joint and interspinous distances usually widened Disk space may be narrowed Neuro deficit in up to 70%

Compression Fracture Flexion injury Anterior wedging of 3mm or more suggests fracture Usually involves superior endplate of vertebral body

Thoracic Spine Injuries Compression fracture Injury to anterior column due to anterior or lateral flexion Middle, posterior column remains intact X-ray - decreased height anterior vertebral body, post body ht normal Amount of ant compression usually less than 40% of post body height Clinically - stable, cord injury rare

Thoracic Compression Fracture Unstable if: Loss of vertebral ht > 50% Angulation more than 20 deg Multiple adjacent compression fractures

Thoracic Spine Injuries Burst Disruption of the middle column Mechanism- axial loading Varying degrees of retropulsion into the neural canal X-ray- spreading of post elements If post elements involved- 50% have neuro injury Neurologic injury more common in: Loss of vertebral ht > 50% Angulation > 20 deg Canal compromise more than 40%

40% compression fracture

Lumbar Spine Fractures Etiology 40% caused by motor vehicle accidents 20% by falls 40% by gunshot wounds, sporting accidents, industrial accidents, and farming accidents

Lumbar Spine Fractures Thoracolumbar spine and lumbar spine are the most common sites for fractures due to the high mobility of the lumbar spine compared to the more rigid thoracic spine Injury to the cord or cauda equina occurs in approximately 10-38% of adult thoracolumbar fractures and in as many as 50-60% of fracture dislocations. Most occur in people younger than 30 years Nearly 60% of patients have serious disabling deficits

Lumbar Spine Injury Lower lumbar spine is the most mobile Isolated fractures of the lower lumbar spine rarely result in complete neurologic injuries Injuries usually results in complete cauda equina lesions or isolated nerve root injuries

Coccygeal Injuries Coccygeal injuries are usually associated with direct falls onto the buttocks Diagnosis of fracture is made on rectal exam Pain with of the coccyx X- rays are not needed Rarely a bony injury Treatment symptomatic Analgesics, rubber doughnut pillow

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