ORTHOPAEDICS II: SPINE AND PELVIS

Pathophysiology, traumatic SCI with a male: female ratio of 2:1. Epidemiological

studies have shown two age-associated peaks in incidence

presentation and of traumatic SCIe in young adults (males: 20e29 years; females:
15e19 years) and in older people (males 70þ; females 60þ). The

management of spinal rising incidence of SCI in the older population reflects the
increased risk of falls. There is also a trend towards more injuries

cord injury being incomplete, which is different to the situation several de-
cades ago, when injuries tended to be complete.
The common causes of traumatic SCI in UK are:
Jan Lee
 50% of injuries result from road traffic accidents
Pradeep Thumbikat  40% result from domestic accidents (e.g. falling down
stairs) and industrial accidents
 10% result from sporting accidents (e.g. diving into
Abstract shallow water, playing rugby, horse riding, gymnastics).
Spinal cord impairment (SCI) may arise from traumatic and non-traumatic
The aetiology and incidence varies throughout the world. For
causes. Traumatic causes include blunt trauma and penetrating injury. Ex-
instance in USA, gunshots and stabbings are often causes of
amples of non-traumatic causes include cord compression from disc pro-
traumatic SCI, whereas in developing countries, falling from
lapse or bone metastasis from a primary cancer. SCI leads to complete
trees and into wells are the most common causes.
loss or altered motor function and sensation, and disruption of autonomic
function. SCI can be described by level of vertebral column injury and by
level and severity of neurological deficit using the International Standards Diagnosis and clinical features of SCI
for Neurological Classification of Spinal Cord Injury developed by the
The diagnosis of SCI should be suspected in patients with the
American Spinal Injury Association as a universal classification tool for
following symptoms:
SCI. This classification tool involves sensory and motor examination to
 neck or back pain
determine neurological level of injury and whether the injury is complete
 sensory disturbance in hands or feet
or incomplete. Acute SCI patients have a complex and evolving patho-
 weakness or paralysis in the upper or lower limb or both.
physiology and it is important to appreciate the altered physiology partic-
Other symptoms which could lead to suspicion of an SCI:
ularly in the acute stages of management. Intensive care monitoring and
 paradoxical chest wall movement
surgical intervention are likely to be required to manage the altered phys-
 priapism in men
iology and vertebral column injuries respectively. A multidisciplinary
 neurogenic shock manifested by hypotension and
approach with specialist SCI centre input ensures optimal management
bradycardia.
from time of diagnosis and has been shown to have a significant effect
The diagnosis of SCI can be missed if there is a lack of sus-
on long-term functional outcome for patients. Since August 2013 a na-
picion and where a detailed neurological examination has not
tional pathway has been in place to facilitate rapid referral from a
been carried out. Other factors which contribute to a missed
major trauma centre to an SCI Centre. The pathway sets out key goals
diagnosis of SCI are intoxicated patients, patients with head
and objectives to be achieved within defined time frames as the patient
injury, patients with incomplete neurological deficit and patients
moves from the acute phase of injury into the rehabilitation and reintegra-
with pre-existing neurological or skeletal conditions such as
tion phase.
multiple sclerosis and ankylosing spondylitis. Therefore in any
Keywords ASIA scoring; autonomic dysfunction; bilateral facet disloca- unconscious or semi-conscious patient where there is difficulty in
tion; neurological level; pressure sores; rehabilitation; spinal cord injury; obtaining a history or carrying out a neurological examination,
unifacet dislocation; vertebral column injury appropriate investigations to rule out SCI must be carried out as
forces to the head sufficient to cause unconsciousness are often
transmitted to the neck and can cause SCI as a result. Ten per
Background cent of patients sustaining traumatic head injury have co-existing
The incidence of SCI in the UK is 12e16 per million of the pop- SCI. There should also be a low threshold for arranging radio-
ulation. Traumatic causes are more common than non-traumatic logical imaging in patients with conditions such as ankylosing
causes (ratio of 4:1), although there is a trend towards an in- spondylitis, where even low-velocity injuries are enough to cause
crease in non-traumatic causes of SCI particularly in older age vertebral fractures.
groups. There is preponderance towards men sustaining a Injuries in elderly patients who sustain hyperextension in-
juries with partial cord damage can be difficult to diagnose, as
patients may be confused and complain of clumsiness or stiff-
ness. Hyperextension injuries usually arise from a low-velocity
injury such as a fall at home. Lacerations or abrasions of the
Jan Lee MRCS (Eng) Academic Clinical Fellow in Spinal Cord Medicine,
forehead are commonly found in these patients. The upper limbs
Specialist Registrar at Princess Royal Spinal Injuries Centre, Sheffield,
are affected more than the lower limbs and this can be explained
UK. Conflicts of interest: none declared.
by the anatomical distribution of axons in the corticospinal tract.
Pradeep Thumbikat FRCS (Glas) Consultant in Spinal Injuries at Princess The fibres for the upper limbs found more centrally suffer
Royal Spinal Injuries Centre, Sheffield, UK. Conflicts of interest: none damage, whereas lower limb fibres found more peripherally
declared. within the corticospinal tract are relatively spared. There may be

SURGERY 33:6 238 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

little radiological evidence of injury. Sometimes an increase in

thickness of the prevertebral soft tissue shadow or opening up of Distribution of sensory dermatomes
the disc anteriorly where the anterior longitudinal ligament has
been torn can be seen. MRI scans usually demonstrate oedema
in the cord and bleeding where there has been ligamentous
injury.

Neurological examination C3
The International Standards for Neurological Classification of C4
T2/3 T2/3
Spinal Cord Injury (ISNCSCI) is a tool used to classify an SCI by T4
C5 5 C5
its neurological level and tests motor and sensory components. 6
The ISNCSCI defines the neurological level as the most caudal 7
C7 C7
level at which sensory and motor functions are intact. The 8
completeness of the injury is graded according to the American T1 9 T1
Spinal Injury Association (ASIA) Impairment Scale (AIS). In a 10
complete injury, there is no preservation of motor or sensory 11
function in the sacral segments S4eS5. In patients with incom- C7 12 C7
plete SCI, there is preservation of the sacral segment and some C8 L1 C8
S5 L2
sensory and motor function preserved below the level of injury.
AIS is graded from A to E, with an ASIA A grade being the most L3 L3
severe injury (complete) e see Table 1.
Evaluation of the sensory function should be carried out first.
Using a disposable safety pin, the examination should start at the L4 L4
side of the neck, progressing down the lateral aspect of the arm,
across the fingers and up the medial aspect of the arm to the
axilla. From the axilla, one should proceed down the side of the
chest and move round to the front of the abdomen. It is impor- L5 L5
tant to assess sensory awareness along the posterior aspect of the
lower limbs and the perineum. A common mistake in assessing
neck injuries is when testing sensation on the chest and
recording a sensory level a few centimetres above the nipples.
Sensation to the upper part of the chest is supplied by the fourth S1 S1
cervical nerve through the supraclavicular nerves and is sepa-
rated from the third thoracic dermatome by an imaginary line
(axial line; Figure 1). Thus injuries of the lower cervical spine Figure 1
can be misdiagnosed as being upper thoracic. The last normal
sensory segment is considered as the neurological level (sensory)
of the patient. In general, changes in muscle power follow the
pattern of pain and temperature loss because their nerve fibre
American Spinal Injury Association impairment scale tracts are closely related in the spinal cord (corticospinal and
spinothalamic tracts respectively).
Category Description
Knowledge of the motor innervation of key muscle groups is
ASIA A Complete e no motor or sensory function is important for carrying out a detailed neurological assessment, as
preserved in the sacral segments S4eS5 shown in Table 2. Once the sensory and motor deficit is elicited,
ASIA B Incomplete e sensory but not motor function the ASIA impairment scoring system can be applied which de-
is preserved below injury level and includes scribes the severity of the injury and carries important functional
S4eS5 and prognostic significance (see Table 1).
ASIA C Incomplete e motor function preserved below
the neurological level and more than half the Anatomy of the spinal cord
key muscles have less than grade 3 power The spinal cord has ascending and descending tracts, the anat-
ASIA D Incomplete e motor function preserved below omy of which is shown in Figure 2.
the neurological level e at least half the key The descending tracts of the spinal cord are responsible for
muscles have grade 3 power or greater motor function and can be broadly grouped into either pyramidal
ASIA E Normal e motor and sensory function are or extrapyramidal tracts depending on where the tracts run. Py-
normal ramidal tracts include the anterior and lateral corticospinal tracts
ASIA, American Spinal Injury Association.
which are responsible for the control of motor function of the
body, and the corticobulbar tracts which are responsible for the
Table 1 control of muscles (such as facial muscles) innervated by the

SURGERY 33:6 239 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

medulla oblongata, anterior and lateral spinothalamic tracts and

Motor innervation of muscles anterior and posterior spinocerebellar tracts.
Muscle Nerves The dorsal column fibres carry fine touch, proprioceptive and
vibratory senses. In the spinal cord the information is carried via
Deltoid C5 the dorsal columns, whilst in the brainstem it is carried by the
Biceps C5 medial lemniscus. The first order neurones carry sensory infor-
Wrist extensors C6 mation to the medulla oblongata where they synapse in the
Triceps C7 cuneate nucleus (from upper limb) or gracile nucleus (from the
Finger flexors C8 lower limb). The second order neurones then decussate (cross
Hand intrinsics T1 over) within the medulla oblongata and travel in the contralat-
Hip flexors L1, L2 eral medial lemniscus to reach the thalamus. The third order
Hip adductors L2, L3 neurones take sensory signals from the thalamus to the primary
Quadriceps L3, L4 sensory cortex of the brain.
Ankle dorsiflexors L4, L5 The anterolateral system consists of the anterior spinothala-
Hamstring L4, L5, S1 mic tracts carrying sensory fibres for crude touch and pressure
Ankle plantar flexors S1, S2 and the lateral spinothalamic tracts carrying fibres for pain and
temperature. It consists of first order neurones arising from pe-
Table 2 ripheral sensory receptors, which enter the spinal cord and
ascend 1e2 vertebral levels and terminate in the tip of the dorsal
cranial nerves. These upper motor neuronal tracts run from the horn (substantia gelatinosa). From here, second order neurones
cerebral cortex to terminate in the brainstem (corticobulbar) or in decussate and carry fibres to the thalamus either via the anterior
the anterior horn of spinal cord (corticospinal). The corticospinal or lateral spinothalamic tracts. The second order neurones syn-
tracts decussate at the ‘pyramids’ of the medulla oblongata; apse with the third order neurones in the thalamus and continue
therefore motor functions are controlled by the opposite side of the to the primary sensory cortex.
brain. Extrapyramidal tracts (rubrospinal, pontine and medullary The spinocerebellar tracts carry unconscious proprioceptive
reticulospinal, vestibulospinal and tectospinal tracts) are found in information and helps with fine-tuning and coordinating motor
the reticular formation of the pons and medulla oblongata and movements.
target neurons in the spinal cord involved in reflexes, fine tuning The anatomical arrangement of these tracts means that due to
of locomotion, complex movements, and postural control. the different levels of decussation of nerve fibres in the different
The ascending tracts of the spinal cord are responsible for tracts, the clinical features can be determined. The decussation of
conveying sensory information from peripheral nerves to the fibres carrying motor function, light touch, proprioception and
cerebral cortex, and include the dorsal column and the medial vibration in the medulla oblongata mean that the patient will
lemniscus which is a continuation of dorsal column fibres in the have ipsilateral deficit. However, decussation of fibres carrying

Figure 2

SURGERY 33:6 240 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

information for pain and temperature occurs at the vertebral temperature sensation but there is preservation of touch, pro-
level of entry of the spinal cord, therefore a contralateral deficit prioception and vibration sense which are carried in the posterior
will be seen. columns.
The blood supply of the spinal cord (Figure 3) is from a single
anterior spinal artery arising from the vertebral artery and paired BrowneSequard syndrome: resulting from traumatic hemi-
posterior spinal arteries arising from the posterior inferior cere- section of the cord leading to ipsilateral loss of motor function,
bellar arteries. The anterior spinal artery supplies the anterior proprioception, fine touch and vibration and contralateral loss of
two-thirds of the cord including the anterior horns and the pain and temperature sensation.
anterior lateral white matter columns. The posterior spinal ar-
teries supply the posterior dorsal column and part of the poste- Posterior cord syndrome: the most uncommon of SCI syn-
rior horns. Twenty-one pairs of segmental radicular arteries dromes, affects the posterior columns of the spinal cord and re-
supply the nerve roots and also contribute to the spinal arteries. sults in loss of proprioception and vibration sense. The
The largest branch of such radicular arteries is often called the presentation is similar to subacute combined degeneration of the
artery of Adamkiewicz, which supplies the lower thoracic and spinal cord (SACD) and tabes dorsalis.
upper lumbar parts of the cord.
Having a clear understanding of the anatomy of the spinal Radiological investigation
cord can help understand the clinical picture and the different
Initial Advanced Trauma Life Support ATLS protocol should be
syndromes that can be seen in SCI.
followed as indicated. If a neck injury is suspected, it is
essential to obtain anteroposterior, lateral and open-mouth
Clinical syndromes of SCI
views of the cervical spine (see Figure 5a). In a modern
SCI can be complete or incomplete as described above (defined trauma centre setting, cross-sectional radiological imaging of
by the presence or absence of sacral sparing). The majority of the spine has superseded radiographs and computed tomogra-
incomplete SCIs can be classified into one of the following syn- phy (CT) is the preferred option. CT imaging is useful in
dromes based on the functional anatomy and the mechanism of providing information about the stability of the fracture, the
injury (see Figure 4). extent of vertebral column injury, the degree of canal
encroachment and the integrity of the posterior elements (see
Central cord syndrome: affecting upper limbs more than lower Figure 5b). Magnetic resonance imaging (MRI) is another
limbs due to the central portion of the cord being affected. This is method of cross sectional imaging and is particularly useful for
common in hyperextension injuries of the cervical spine in looking at soft tissue damage, disc injuries and ligamentous
elderly patients. injury (see Figure 5c).
Where standard radiographs are used, certain techniques may
Anterior cord syndrome: affecting the anterior two thirds of the be used to enhance the views obtained: shoulder pull-down
spinal cord which causes loss of motor function and pain and views and swimmer’s views are helpful when the C7eT1

Blood supply of the spinal cord

Area supplied by
anterior spinal artery
Anterior spinal artery

Anterior radicular artery Spinothalamic tract

Lateral spinal artery Corticospinal tract

(pyramidal pathways)

Gracile fasciculus and

Posterior radicular artery
cuneate fasciculus

Area supplied by
Posterior spinal artery posterior spinal artery

Figure 3

SURGERY 33:6 241 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

Clinical syndromes of SCI

Anterior cord Brown–Séquard

syndrome syndrome

Posterior cord Central cord

syndrome syndrome

Figure 4

junction is not clearly seen. Oblique views of the lower facets Acute management of SCI
may be informative, especially when dislocations are suspected.
The initial assessment should follow ATLS guidelines to
High-velocity injuries (e.g. from road traffic accidents) have a
adequately assess and stabilize the patient. A good understand-
high incidence of spinal fractures at more than one level (non-
ing of the pathophysiology and complications of SCI is important
contiguous injuries). Therefore radiological imaging should
in managing the patient appropriately. Careful fluid management
cover the entire spine.
is essential to avoid overloading in an attempt to correct hypo-
The thoracic spine is a relatively fixed structure with mobile
tension. Initial management of SCI requires a swift and accurate
segments at either end. Thus fractures tend to occur at the cer-
diagnosis of SCI and multisystem physiological stabilization to
vicothoracic and the thoracolumbar junctions, where mobile
minimize impairment and prevent further disability.
segments meet rigid segments.

Figure 5 C6 fracture with a burst component. (a) Radiograph (lateral view) of the cervical spine, (b) axial CT and (c) T2-weighted sagittal MRI show fracture
extending across the three columns, causing extensive injury to the cord (bright signal within cord). The bright signal change in c along the anterior
aspect of the vertebral bodies (arrow) suggests ligament damage. The posterior elements of C4 are seen fractured in a (arrows). CT is most useful in
delineating bony injury; MRI help to identify the extent of cord damage, disc injuries and ligamentous damage.

SURGERY 33:6 242 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

Autonomic dysfunction Anticoagulation for risk of venous thromboembolism

Autonomic dysfunction occurs particularly in cervical and high Before the introduction of prophylactic anticoagulation, pul-
thoracic lesions due to the loss of sympathetic outflow as a result monary embolism was the most common cause of death
of damage to sympathetic nerves fibres. Preganglionic sympa- following SCI. If there is no contraindication, low molecular
thetic fibres originate from the intermediolateral nucleus of the weight anticoagulation is commenced 24 hours post injury as
lateral grey column from the first thoracic vertebra to the second per individual hospital policy for venous thromboembolism
lumbar vertebra, and synapse with postganglionic fibres para- prophylaxis. The thromboprophylaxis should continue for a
vertebrally. Loss of sympathetic input causes peripheral vasodi- 3-month period, either using low molecular weight heparin or
lation and consequent hypotension (neurogenic shock). The warfarin. If using warfarin, an international normalized ratio
hypotension can be profound and it is not uncommon for a C5 (INR) or 2e2.5 should be aimed for. Chemical prophylaxis
tetraplegic in the acute phase to have a systolic blood pressure of should be combined with mechanical measures such as
less than 90 mmHg. Severe bradycardia is also common. compression stockings, sequential calf compression and
Orthostatic hypotension commonly occurs due to loss of supra- frequent turns of the patient.
spinal control of sympathetic nervous system below the level of
the lesion. In patients with cervical or high thoracic lesions, there Respiratory problems
is either a reduction in systolic blood pressure 20 mmHg or a Patients with lesions below C5 are generally able to ventilate
reduction in diastolic blood pressure 10 mmHg when the pa- adequately, unless they have pre-existing respiratory problems.
tient is moved from supine to standing or sitting position. Cervical injury and high thoracic lesions cause paralysis of the
Orthostatic hypotension can be treated with conservative mea- intercostal muscles and acute loss of muscle tone. This results in
sures by compression bandages or stockings, ensuring adequate in-drawing of intercostal spaces during inspiration and a dia-
fluid intake and avoidance of diuretics. If conservative measures phragmatic/abdominal pattern of breathing (paradoxical
are not effective, pharmacological therapy with sympathomi- breathing). Presence of paradoxical breathing should raise the
metics such as ephedrine and midodrine can be helpful. suspicion of a high spinal cord injury or flail chest. High SCI is
SCI associated with high-velocity trauma (e.g. road traffic associated with significantly reduced vital capacity.
accident) often occurs along with other injuries such as haemo- In polytraumatized individuals, where other respiratory in-
thorax or intra-abdominal bleeding which can result in hypo- sults such as haemothorax, pneumothorax, fractured ribs and
volaemic shock requiring rapid fluid resuscitation. lung contusions might co-exist, these can contribute to respira-
Hypovolaemic shock is accompanied by hypotension, poorly tory failure. Ascending neurological deficit can cause delayed
perfused peripheries and tachycardia, although the tachycardia respiratory failure due to diaphragmatic paresis. Thus monitoring
may not be obvious in those with high SCI. This should be of respiratory rate, oxygen saturation and vital capacity should
carefully distinguished from hypotension in isolated SCI that be carried out regularly and can provide early indication of
occurs due to autonomic dysfunction. Neurogenic shock is impending respiratory insufficiency.
associated with hypotension and bradycardia, and the treatment Effective coughing and failure to clear chest secretions can be
of this is with sympathomimetics rather than fluid replacement, problematic in cervical and high thoracic injuries where there is
although modest amounts of fluid may be given to fill the paralysis of abdominal wall muscles. Therefore assisted cough-
vascular space. Due to lack of understanding of the abnormal ing, respiratory physiotherapy and breathing exercises should be
physiology that occurs in SCI, a common mistake is to use commenced at the earliest opportunity to minimize respiratory
excessive fluid resuscitation in a patient with uncomplicated SCI, complications.
which can lead to fluid overload and pulmonary oedema. This
can be particularly damaging in SCI patients with cervical lesions Abdominal problems
who are already dealing with an acute fall in respiratory reserves The presence of major intra-abdominal trauma can be difficult to
as a result of loss of intercostal muscle function, therefore it is of detect in complete SCI due to absence of pain or guarding.
upmost importance to appreciate this altered physiology in SCI Examining for signs such a bruising or distension is important.
patients and to prevent unnecessary fluid resuscitation. Haematuria may be indicative of renal trauma and may suggest
Due to the damage to sympathetic fibres, there is unopposed other visceral injury.
vagal activity (parasympathetic) on the heart which causes Paralytic ileus almost always develops, although bowel
bradycardia. The resultant bradycardia can be so severe that sounds may still be present in early stages of injury. The ileus
cardiac arrest can occur. Often in trauma settings, endotracheal should be managed with a ‘nil by mouth’ approach and a
intubation and suction of respiratory suctions is necessary. Such nasogastric tube is passed if abdominal distension is present.
procedures can cause stimulation of the vagus nerve and can Care must be to taken to ensure the abdomen does not become
exacerbate bradycardia. If these procedures need to be carried unduly distended as this can compromise diaphragmatic move-
out, care needs to be taken to avoid worsening of the bradycardia ment and cause respiratory insufficiency.
and an anti-muscarinic agent such as atropine or glycopyrrolate There is an increased risk of stress peptic ulceration
should be given prophylactically. following SCI which should be prevented with prophylactic H2
Inability for the body to respond to changes in environmental receptor blockers and proton pump inhibitors. Due to lack of
temperature is common in individuals with SCI due to autonomic abdominal symptoms and signs, perforated gastric ulcer can be
dysfunction compromising regulation of body temperature. Care difficult to diagnose, if suspected radiological imaging should be
should be taken to avoid the hyper- or hypothermia that can carried out which may show presence of free gas intra-
result. abdominally.

SURGERY 33:6 243 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

Bowel management Skin over the shoulder blades and other pressure areas must
Most patients with significant SCI suffer from neuropathic bowel be carefully inspected at regular intervals. Due to the loss of
and bladder dysfunction. sensation and motor ability, pressure sores can develop rapidly
In initial stages of SCI, the rectum is flaccid and per rectal therefore regular turning of the patient every 2 or 3 hours is
digital examinations to evaluate tone and rectal filling should be essential to prevent this. It is of upmost importance to keep the
carried out daily. Once bowel function returns as denoted by skin dry and to inspect the skin thoroughly at every turn, with
passage of flatus and faeces, digital evacuation should be insti- particular attention to pressure areas. Pressure must be kept off
tuted on a daily basis or on alternate days. Once there is a return any persistent red areas of skin.
of reflex anal activity, evacuation can be achieved using digital
stimulation, suppositories or micro-enemas. Additional laxatives Management of SCI
to bulk and soften the stool and to enhance intestinal transit may
Management of vertebral column injury can be either conserva-
be required.
tive or through surgical fixation. The details regarding different
Bladder management surgical fixations are beyond the scope of this article.
Until the patient is stabilized, the bladder should be drained with
Principles of vertebral column management
an indwelling catheter which also allows close monitoring of
Maintenance of alignment: maintenance of cervical vertebral
urine output. Once the patient’s condition is stabilized, clipping
alignment is important in preventing secondary injury and
and releasing of the catheter is commenced to replicate ‘normal
improving prospects for recovery. Skull traction can be applied to
bladder activity’ and the catheter is subsequently removed to see
cervical injuries to establish and to maintain alignment. Gardner
if a reflex bladder exists. The preferred option of bladder man-
eWells callipers (which have a built-in tension indicator) are the
agement is with regular clean intermittent self-catheterization if
simplest and safest to apply. The calliper pins are sited about 2
the patient has sufficient hand dexterity. However, in individuals
cm above the ears (in line with the external auditory meatus).
with poor hand function and a reflex bladder with low residual
Traction along this line produces the required extending moment
volumes post micturition, a condom drainage system can be
about the neck. A larger extending moment can be applied by
used. An alternative is insertion of a suprapubic catheter. In
positioning the callipers further forward, but fixation of the
those with lesions above the conus medullaris (T12/L1), it is
temporalis muscle by the pins can result in trismus. The force
common to find an upper motor neuron pattern of bladder
needed to maintain alignment varies; for example, it is 2 kg in a
function characterized by reflex contractions, detrusor sphincter
frail elderly patient with a high cervical fracture and 5 kg in a fit
dyssynergia and reduced bladder capacity.
young man with a low neck injury.
Role of the multidisciplinary team If there is major disruption, large forces over long periods can
A multidisciplinary, multi professional approach is essential to cause considerable distraction at the fracture site and put traction
get optimum outcomes. on the cord. An alternative to traction for maintaining alignment
Early chest physiotherapy involving assisted coughing and in selected cases is a well-fitted halo jacket.
breathing exercises is vital for all patients with SCI, especially
those with previous respiratory conditions or associated chest Reduction of facet dislocation: early reduction of a cervical
trauma. dislocation has been shown to be associated with improved
Joint and muscle contractures can develop rapidly causing neurological recovery. Once reduction has been achieved,
movement restrictions. Prevention of contractures is vital and alignment needs to be maintained with appropriate in-
passive joint movements in the upper and lower limbs needs to terventions. Reduction of facet dislocation requires traction
be commenced post injury. Care must be taken in managing forces much greater than for maintenance of alignment.
tetraplegic patients with regards to upper limb positioning and Unifacet dislocation e awake reduction is the safest method
splinting. In those with lumbar fractures, hip flexion should be as the patient is able to provide guidance on sensory motor sta-
limited to 70 degrees to avoid unrolling of the lumbar lordosis. tus. The dislocated facet can be determined by observing the
Good shoulder movement needs to be maintained, as stiff painful patient from the head of the bed; the chin is often turned away
shoulders can compound subsequent disability and this is from, and the head tilted towards, the side of the dislocation.
particularly important in elderly patients. Classically, on the lateral radiograph there is a forward shift of
Nursing care is directed towards maintaining alignment of the about 25% of vertebral body diameter of the upper vertebra on
spine and preventing skin damage. All manoeuvres must be the one below (Figures 6a, b and 7). The initial attempt at
carried by trained staff and often require at least three people reduction comprises the application of axial traction. If, however,
acting in unison. Dedicated turning beds such as Stoke-Egerton the dislocation is unresponsive, the neck may be slightly flexed
bed help maintain alignment of the spine when turning. Those and the head turned away from the side of the dislocation to
with thoracolumbar injury must be ‘log-rolled’ onto their side unlock the facet. Traction is increased by 2 kg every 10e15
with a long thin lumbar pillow positioned in the hollow of the minutes to allow the tissues to stretch. Traction weights of 30 kg
back. Patients with cervical injury must maintain their shoulders or more are often required, and reduction with as much as 70 kg
flat on the bed to keep cervical and upper thoracic spine aligned, has been reported. Radiographs are taken with each increment in
with the pelvis twisted to bring one leg upper most, pillows are weight until the dislocation is reduced, whereupon the neck is
then applied to this leg and the back to relieve pressure on the brought into extension and the weights reduced to maintenance
sacrum and upper buttock. level. The patient is questioned and examined repeatedly for

SURGERY 33:6 244 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

Figure 6 (a) Radiograph (lateral view) of the cervical spine of an unifacet dislocation of C5 on C6. (b) Facet views of the same injury as in a. The loss of
apposition of the facet surfaces (arrows) and the change in rotational alignment of the spine are evidenced by the visibility of the neural foraminae below
the level of the dislocation and the facet articulations above.

changes in neurology during this period. The final phase of the emergency surgery is occasionally necessary. Once reduction is
reduction may be facilitated by giving intravenous benzodiaze- achieved conservative or operative management can be decided
pines to relax the paraspinal muscles; the dose should be titrated upon depending on the level of injury, neurological completeness
so that the patient is not rendered unresponsive to questioning or and the severity of comorbidities. Operative management is
examination. commonly undertaken now, as it helps with nursing and
Manipulative reduction under general anaesthetic may be commencement of rehabilitation.
required if awake reduction fails. It should (if time and neurology In patients with partial neurological lesions, reduction is best
allow) be carried out after obtaining MRI scans of the neck to achieved as soon as possible; late reduction can cause neuro-
exclude a concomitant disc prolapse. Anaesthesia carries the risk logical deterioration e this may be due to oedema in the cord
of not being able to monitor the patient’s neurology, and is best and vascular compromise rendering it more sensitive to the
undertaken by those with experience of the technique. If uni- trauma of manipulation.
lateral facet dislocations cannot be reduced by the above means, Bilateral facet dislocation e a patient with bilateral facet
dislocation who is neurologically intact is in an extremely
dangerous situation. Early reduction should be carried out. If
initial traction is unsuccessful then immediate open reduction
should be performed. If traction succeeds in reducing one of the
facets, there is some added stability and open reduction can be
carried out in a planned manner (Figure 8).
Surgical fixation e after successful reduction, the ligamen-
tous disruption that occurs with facet dislocation is best treated
by fixation.

Thoracolumbar injuries
The three-column classification of thoracolumbar injuries by
Francis Denis in 1983 is the easiest to use in the clinical setting.
More recently, there has been a shift to viewing the spinal col-
umn as a two column construct, as first postulated by Holds-
worth. These biomechanical concepts help to define unstable and
stable vertebral column injuries.
Serious thoracolumbar injuries can be managed conserva-
tively or by internal fixation. In a modern setting, most unstable
thoracolumbar injuries are managed surgically. Limited instru-
mentation should be carried out to avoid loss of movement,
Figure 7 Radiograph (anteroposterior view) of unifacet dislocation of C6
on C7, showing an increase in the interspinous process distance (arrows), which can otherwise interfere with function later in the course of
and a shift of the alignment of spinous processes above the level of the rehabilitation. Conservative management may involve 6e10
dislocation towards the side of the dislocation. weeks of nursing flat in bed followed by mobilization in a spinal

SURGERY 33:6 245 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

Role of surgery
The goals of surgical management in the SCI patient are to sta-
bilize the spine, to decompress the spinal canal, and to prevent
further neurologic injury. Surgical fixation helps with nursing
and early mobilization of the SCI patient. Whether decom-
pressive surgery aids neurological recovery remains unproven. It
certainly carries a small risk of neurological deterioration in pa-
tients with incomplete cord injury. Decompressive laminectomy
should not be carried out on its own as it increases the instability
at the fracture site. Modern anterior and posterior fixation de-
vices (Figures 9 and 10) have reduced, but not totally solved the
problems of implant failure and loss of correction.

Timing of surgery
There is currently no convincing evidence to suggest that early
surgical stabilization or decompression improves neurological
outcomes. A multicentre, international, prospective cohort study
(Surgical Timing in Acute Spinal Cord Injury Study: STASCIS) in
Figure 8 Radiograph (lateral view) of the cervical spine showing a bifacet adults aged 16e80 with cervical SCI comparing early versus
dislocation of C5 on C6. The loss of apposition of the facet surfaces and delayed surgical intervention was published in 2012. The study
complete disruption of the posterior ligamentous complex are evidenced
suggested that decompression prior to 24 hours after SCI can be
by the distance between the spinous processes (arrows).
performed safely and is associated with improved neurologic
brace. Abandonment of conservative treatment should be outcome, defined as at least a two-grade AIS improvement at 6
considered if: months follow-up. However the study was associated with
 There is continued progression of a neurological lesion methodological flaws including having a hitherto not used pri-
after admission. mary outcome measure, having a ceiling effect, inclusion of
 Displacement of the fracture precludes conservative cervical dislocations in the study group (where there is evidence
management. early reduction, surgical or non-surgical, helps neurological
 Surgery may improve nerve root recovery at the site of the outcome) and the difficulties in obtaining reliable AIS scores in
injury. the first 24 hours. At the time of writing this article, there is an
 Associated injuries (e.g. head and chest injuries) can be ongoing prospective European multicentre study addressing the
better managed following fixation of the spine. role of early surgery.

Figure 10 Anterior decompression and fixation with a Moss cage and

Figure 9 Interpedicular fixation of a fracture/dislocation. Kaneda Fixator.

SURGERY 33:6 246 Ó 2015 Published by Elsevier Ltd.

 ORTHOPAEDICS II: SPINE AND PELVIS

SCI referrals pathway logistics, capacity determination, future planning and auditing
services and outcomes. A
A standardized national SCI management pathway was intro-
duced in August 2013 in the UK. This outlines a clear protocol
for management of SCI with defined time frames of when FURTHER READING
certain objectives need to be achieved and is separated into Bickenbach J, Officer A, Shakespeare T, von Groote P, eds. International
physical and psychological needs as well as goals for inde- Perspectives on Spinal Cord Injury. Geneva: World Health Organ-
pendence. The aim is to ensure a standardized approach for ization/The International Spinal Cord Society; 2013.
optimal and efficient management of SCI patients from the Denis F. The three column spine and its significance in the classification of
acute phase into the rehabilitation and reintegration phase. acute thoracolumbar injuries. Spine 1983; 8: 817e31.
The protocol emphasizes an importance in having effective Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decom-
and early communication between trauma units and SCI cen- pression for traumatic cervical spinal cord injury: results of the Sur-
tres and having better links between hospitals providing initial gical Timing In Acute Spinal Cord Injury Study (STASCIS). PLoS One
care and SCI centres through outreach support. Early advice 2012; 7: e32037. http://dx.doi.org/10.1371/journal.pone.0032037.
given from SCI centres and early transfer to an SCI has been Published online 2012 Feb 23.
shown to reduce complications of SCI and improve outcomes. Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards
All newly diagnosed SCI need to be registered on the National for neurological classification of spinal cord injury (revised 2011).
Spinal Cord Injury Database. This allows for management of J Spinal Cord Med Nov 2011; 34: 535e46.

SURGERY 33:6 247 Ó 2015 Published by Elsevier Ltd.