Trauma to the Spine and Spinal Cord

epidemiology Occurrence 20-80 per 100,000 2 deaths per 100,000 population due to spinal injury male/female ratio 3/1

Etiology (USA) 40% - motor vehicle accidents 20% - falls 15% - industrial 15% - sports and recreation

Denis tree-column theory anterior posterior column . middle

Mechanisms of spine injury Flexion Flexion-rotation Extention Compression

Mechanisms of injury Compression Flexion Flexion-Rotation.

Shear. Flexion-Distraction. Extension

Classification of injury to the spine Depending on integrity of the skin Closed open, depending on integrity of dural sac missile nonmissile Clinical forms of injury to the spine contusion Injury to the ligaments and capsules Rupture of intervertebral disk Facet dislocation Complete bilateral facet dislocationn (locked facets) Fracture of vertebra corpus (compressive, burst) Fractures of posterior elements of vertebras (joint, transverse, spinous processes and arch) Fracture-dislocation (unilateral and bilateral) Multiple fractures of vertebra elements Violation of support function Stable Instable

Types of injury to the cervical spine Occipital condyle fractures Atlanto-occipital dislocation Fractures of the atlas Jefferson fracture Fracture of posterior arch Axis fractures Fractures of the odontoid process (I-III types) Lateral mass fractures Traumatic spondylolisthesis (hangman's fracture)

Atlanto-occipital dislocations

Traumatic spondylolisthesis (hangman's fracture)

Fracture of odontoid process of C2 (type II)

Types of injury to the cervical spine Fractures and dislocations of C3-C7 Compression fractures Burst fractures Teardrop fractures Unilateral facet dislocation Bilateral facet dislocation (locked facets) hyperextension dislocation hyperextension fracture-dislocation laminar fractures Fracture of spinous process

Compressive fracture of С5

Unilateral facet dislocation of C4-C5

dislocation of С4

Edge compressive fracture of С7, dislocation С6, compression of spinal cord

А-normal Б-subluxation В-dislocation Г- complete dislocation with locked facets

Complete dislocation of C5 (bilateral locked facets with severe compression of spinal cord

Burst fracture С3-С4 with із severe spinal cord compression

Typical injuries to the thoraco-lumbalis and lumbalis spine Wedge compression fractures Burst fractures Seat belt–type injuries Fracture-dislocations

Wedge compression fracture

Burst fractures

Seat belt–type injuries

Fracture-dislocations

Classification of the injury to the spinal cord Complete syndrome – total loss of motor and sensory function below injury level central cord syndrome – weakness of the upper extremities greater than the lower extremities anterior cord syndrome total loss of motor and lateral column sensory function (pain and temperature), dorsal column function (i.e., proprioception, touch, and position sense) is spared conus medullaris syndrome combination of spinal cord and nerve root involvement Cauda equine syndrome Brown-Sequard syndrome

Scheme of blood supply of spinal cord and typical ischemical changes 1-vertebral arteria 2-5-radicular- medular arteries 6-spinal cord А – loose type of blood supply Б,В,Г – variants of magistral types of bood supply

Classification of spinal cord injury Frankel (A) complete, (B) sensory only, (C) motor useless, (D) motor useful, (E) recovery.

Prehospital care ABC Immobilization - rigid cervical collar, backboard A (airway), cleaning, airway tube if indicated B (breathing) – supplemental oxygen of mask C (circulation) – maintaining normal blood pressure – fluids Immobilization - rigid cervical collar, backboard

Emergency room management ABCDE Cont ABC protocol Supplemental oxygen for all Fluids and pressors for maintaining normal blood pressure D - (disability) - assessment of neurological status E – (exposure) - removal of all clothes for throughout examination methylprednisolone - iv bolus of 30 mg per kg followed 5.4 mg per kg per hour continuous infusion during the next 23 hours.

Treatment of cervical spine injury Cervical traction Reduction of dislocation Manual reduction Traction Immobilization with orthoses Collars Cervicothoracic, thoracolumbar braces Halo-orthosis Surgical decompression and stabilization

Typical indications for surgery Almost all thoraco-lumbar injuries with neurological deficit thoraco-lumbar injuries without neurological deficit in cases of progressive deformation (kifosis) Cervical burst fractures and fractures-dislocation Other cervical injuries after ineffectiveness of conservative treatment (cervical traction, manual reposition, halo-orthoses)

Accompanying problems and complication Dysfunction of bladder and bowel Urinary infection Decubitus (trophic ulcers) Spasticity (late) Progressive deformation of the spine

Diagnostic procedures Plain X-ray examination (min 2 views) Functional X-ray examination CT Myelography and postmyelography CT MRI CSF dynamic tests

Reposition of cervical spine dislocations А- traction Б- bending to the “healthy” side В- rotation to the opposite side

Hallo apparatus for stabilization of cervical fractures

Tongs of distraction and stabilization of injury to the cervical spine

Surgical stabilization Corporodesis C3-C5, anterior approach

Surgical stabilization Transpedicular fixation

Posterior spondilodesis with bone graft

Scheme of anterior spondylodesis

Posterior spondilodesis with metal wire