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

3. 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 years
Approximately 80% of patients are male

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

5. 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.

6. Blunt trauma
Motor vehicle accidents
Falls
Exlopsive injuries
Sport injuries

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

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

10. 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.

11. 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.

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

13. 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

14. Log rolling

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

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

17. 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…

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

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

20. Initial Assessment
Dermatomes

21. Reflex Examination

24. 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

25. 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

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

27. 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

28. 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

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

30. 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

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

32. CT Scan
L3 unstable burst fracture

33. MRI Scan
Thoracic fracture subluxation with increased signal in conus medullaris

34. 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

35. 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

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

37. 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

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

39. 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

40. 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)

41. 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

42. 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

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

44. 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.

45. 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

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

47. 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.

48. 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

49. Treatment
Non-operative Treatment
Surgical Treatment
Rehabilitation

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

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

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

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

54. 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

58. 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.

59. 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.

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

62. 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

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

64. 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%)

67. 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

68. 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

69. Hangman

70. 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%

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

72. 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

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

74. 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%

75. 40% compression fracture

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

77. 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

78. 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

79. 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

80. Thank You