Spine Fractures and Spinal Cord Injury

SPINE FRACTURES AND
SPINAL CORD INJURY

General Outlines
Introduction
Mechanism of Injury
Radiological Examination
Classification
Management
Patient Evaluation
ABC’s of ATLS
History
Physical Examination
Neurological Classification
Main Problems in TL Fractures
Find :
1. Instability
2. Neurological Deficit
Clinical Assessment
Inspection
Palpation
Neurological Evaluation
ASIA Impairment Scale
Sensory Evaluation
Motor Evaluation
Reflex Evaluation
Bulbocavernosus
70% patients do not present with neurological deficit

Spinal Cord Injury
Pathophysiology
Primary injury
• Damage to
neural tissue due
to direct trauma
• Irreversible
Spinal Cord Injury
Pathophysiology
Secondary injury
Injury to adjacent tissue
due to :
• Decreased perfusion
• Lipid peroxidation
• Free radical / cytokines
• Cell apoptosis
Most acute therapies aim to limit secondary injury cascade

Methylprednisone used to prevent secondary injury by improving perfusion,
inhibiting lipid peroxidation, and decreasing the release of free radicals
Spinal Cord Injury
Pathophysiology
1970’s : free radicals
1980’s : Ca, opiate receptors

lipid peroxidation
1990/2000’s: apoptosis
intracellular protein synthesis glutaminergic
mechanisms
Secondary Injury Cascade
Current Understanding
Spinal

Shock
Physiologic disruption of all spinal cord function
24-72 hour period of paralysis, hypotonia, & areflexia
Return of reflex activity below level of injury indicates
end of spinal shock
Bulbocavernosus Reflex
Injuries below L2 do not produce spinal shock
Bulbocavernosus Reflex
Spinal Cord Injury
Classification
Complete injury Incomplete injury
 an injury with no spared an injury with some
motor or sensory function preserved motor or sensory
below the affected level. function below the injury
 Patients must have recovered level
from spinal shock Include :
(bulbocaernosus reflex is  Anterior cord syndrome
intact) before an injury can be  Brown-Sequard syndrome
determined as complete  Central cord syndrome
 Classified as an ASIA A  Posterior cord syndrome
Classification
Complete
• Absence of sensory & motor function in lowest
sacral segment after resolution of spinal shock
Incomplete
• Presence of sensory & motor function in lowest
sacral segment (indicates preserved function
below the defined neurological level)
Spinal Cord Injury
Classification
1. Determine if patient is in spinal shock
 check bulbocavernosus reflex
2. Determine neurologic level of injury
 lowest segment with intact sensation and
antigravity (3 or more) muscle function strength
 in regions where there is no myotome to test, the
motor level is presumed to be the same as the
sensory level.
Classification
Incomplete SCI syndromes
Central Cord Syndrome

• Most common incomplete SCI
• Hyperextension mechanism
• Motor loss UE>LE
• Hands affected
Central gray matter
• Preserved sacral sparing
• Common in elderly w/ pre-existing
spondylosis and cervical stenosis.
• Substantial recovery can be
expected (permanent clumsy hand)
• Good prognosis
Classification
Anterior Cord Syndrome

• Motor loss LE>UE
• Vibration/position
spared
• Flexion injuries Spinothalamic & corticospinal
tract out, posterior collum
• Poor prognosis for spared
recovery (worst
prognosis)
Classification
Brown Sequard
• Ipsilateral motor,
proprioception loss.
• Penetrating trauma
• Contralateral pain,
temperature loss. Lateral haft of spinal cord
• Penetrating injuries. (hemissection)
• Good prognosis for

ambulation (excellent
prognosis)
Classification
Posterior Cord Syndrome

• Profound sensory loss.
• Pain/temperature less
affected.
• Rare. Posterior Collum
Initial evaluation
Primary survey
 Airway
 Breathing
 SCI above C5 likely to require intubation

 Circulation
 Initial survey to inspect for obvious injuries of head and spine
 visual and manual inspection of entire spine should

be performed
 seat belt sign (abdominal ecchymoses) should
raise suspicion for flexion distraction injuries of

thoracolumbar spine
Initial evaluation
Secondary survey
 cervical spine exam
 remove immobilization collar
 examine face and scalp for evidence of direct trauma
 inspect for angular or rotational deformities in the holding
position of the patient's head

 rotational deformity may indicate a unilateral facet
dislocation
 palpate posterior cervical spine looking for tenderness along
the midline or paraspinal tissues

 absence of posterior midline tenderness in the awake, alert
patient predicts low probability of significant cervical injury.

 log roll patient to inspect and palpate entire spinal axis
 perform careful neurologic exam

Clinical Cervical Clearance
•Removal of cervical collar WITHOUT
radiographic studies allowed if
•patient is awake, alert, and not intoxicated
AND
•has no neck pain, tenderness, or neurologic
deficits AND
•has no distracting injuries
•Nexus critieria for pediatric C-spine clearance

•less radiation expsosure with reduced CT

scans for C-spine clearance
Radiographic Cervical
Clearance
Indications for obtaining radiographic clearance
intoxicated patients OR
patients with altered mental status OR
neck pain or tenderness present OR
distracting injury present
Xray
AP, Lateral, Open Mouth odontoid view (must included Th1)
Flexion-extnsion radiograph rulling out instability, only performed in
awake and alert patient
CT-Scan to bottom 1st Th
MRI  for soft tissue injuries, disc herniation, posterior ligament injuries,
spinal cord changes, high rate false positif, effective within 48 h of injury
MR and CT angigraphy  evaluating v. artery
X-Ray
look for subtle

abnormalities such as
-soft-tissue swelling
-hypolordosis
-disk-space narrowing or
widening
-widening of the
interspinous distances
Open Mouth
Thoracolumbar Injury Classification and
Severity Score (TLIC)
Definitive Treatment
Nonoperative
Bracing and observation
 indications
 most GSWs
 exceptions listed below
 metastatic CA patients with < 6 mos life expectancy
 presence of six variables below correspond to short life expectancy
 multiple spinal mets

 multiple extraspinal mets
 unresectable lesions in major organs
 SCI (complete or incomplete)
 aggressive CA: lung, osteosarcoma, pancreas
 critically ill
Prognosis
Most important prognostic variable relating to
neurologic recovery is completeness of the
lesion (severity of neurologic deficit)
Only 1% have complete recovery at time of hospital
diagnosis
Conus medullaris syndrome has a better prognosis for
recovery than more proximal lesions
ASIA Impairment Scale
ASIA Motor Score & Level
 6 point scale
 0 = total paralysis
 1 = palpable or visible contraction
 2 = active movement, full ROM with gravity eliminated
 3 = active movement, full ROM against gravity
 4 = active movement, full ROM against moderate resistance
 5 = (normal) active movement, full ROM against full resistance
 Key muscles:
 C5 - Elbow flexors (biceps, brachialis)
 C6 - Wrist extensors (ECRL, ECRB)
 C7 - Elbow extensors (triceps)
 C8 - Finger flexors to the middle finger (FDP)
 T1 - Small finger abductors (AbDM)
 L2 - Hip flexors (iliopsoas)
 L3 - Knee extensors (quadriceps)
 L4 - Ankle dorsiflexors (tibialis anterior)
 L5 - Long toe extensors (EHL)
 S1 - Ankle plantarflexors (gastrocnemius, soleus)
 Other muscles also evaluated but their grades are not used in determining motor score or motor
level [diaphragm (fluoro), deltoids, abdominals (Beevor's sign), medial hamstrings, hip adductors -
graded as absent, weak or normal; anal sphincter - Yes/No].
 For myotomes not testable, the motor level is presumed to be the same as the sensory level.
 Motor level (L or R), defined by the lowest key muscle that has a grade of at least 3, provided the key
ASIA Sensory Score & Level
 Pin prick and light touch
 0 = absent
 1 = impaired (partial or altered, including hyperaesthesia
 2 = normal
 Key sensory points:

 C2 - Occipital protuberance
 C3 - Supraclavicular fossa
 C4 - Top of the acromioclavicular joint
 C5 - Lateral side of antecubital fossa
 C6 - Thumb
 C7 - Middle finger
 C8 - Little finger
 T1 - Medial side of the antecubital fossa
 T2 - Apex of the axilla
 T3 - Third intercostal space (IS)
 T4-11 - Respective IS
 T12 - Mid-point inguinal ligament
 L1 - Midway between T12 and L2
 L2 - Mid-anterior thigh
 L3 - Medial femoral condyle
 L4 - Medial malleolus
 L5 - Dorsum of the foot at 3rd MTPJ
 S1 - Lateral heel
 S2 - Mid popliteal fossa
 S3 - Ischial tuberosity
 S4-5 - Perianal area
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral
segments S4-S5
B Incomplete Sensory but not motor function is preserved below the

neurological level and includes sacral segments S4-S5
C Incomplete Motor function is preserved below the neurological

level, and more than half of the key muscles below the
neurological level have a muscle grade of less than 3
D Incomplete Motor function is preserved below the neurological

level, and at least half of the key muscles below the
neurological level have a muscle grade of 3 or more
E Normal Motor and sensory function is normal
Key muscles: L2 = iliopsoas; L3 = quadriceps; L4 = Tib ant; L5 = EHL; S1 = gastrosoleus

Spinal Instability
Clinical
Spinal deformity
Posterior spinal haematoma, widened gap
between spinous processes
Presence of neurological deficit
Radiological
Clinical Assessment
Associated Injuries
28% have other major organ system injuries
Noncontiguous spine fractures 3-17%
Always monitor hematocrit and urine output
Urinary – Foley recommended,
GI – prepare for ileus
Retroperitoneal bleeding from fracture
 Gastroparesis from trauma
Meyer ‘85
Radiographic Evaluation
Initial Trauma Series: (Classic ATLS)
Lateral cervical, chest, AP pelvis
Secondary spine films determined by individual
condition and MOI
Trauma protocols with CT scans of chest, abd.

and pelvis provide much more information;
Challenges necessity for plain films
Obtunded patients require further skeletal

survey, secondary survey essential
Evaluation
Additional Imaging
CT scan – bony injuries
MRI – soft tissue imaging:

Spinal cord, intervertebral discs, ligamentous structures
a complementary role and is useful in the assessment of patients
with neurologic deficit
 for evaluation of the posterior ligamentous complex (PLC)
 supraspinous ligament (SSL),
 interspinous ligament (ISL),
 ligamentum flavum (LF)
 The facet joint capsules
Compression
Fracture
* *
Burst Fracture
* *
*
Flexion-distraction
Injury
(Chance)
Flexion-distraction (Chance)
injuries
Fracture Dislocation
*
* *
*
Aims of Treatment
Restore alignment and stability to spinal column
Improve neurological status
Facilitate mobility and rehabilitation
Surgical vs. Non-surgical treatment

CONSERVATIVE TREATMENT
Used only for minor and stable fractures
Bed rest
X Postural reduction (lumbar spine)
Ambulatory treatment
Spinal jacket (TLSO)
Free ambulation to pain tolerance
Thank You

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SPINE FRACTURES AND

SPINAL CORD INJURY

70% patients do not present with neurological deficit

Most acute therapies aim to limit secondary injury cascade

1970’s : free radicals

1980’s : Ca, opiate receptors

Central Cord Syndrome

Anterior Cord Syndrome

• Good prognosis for

Posterior Cord Syndrome

 SCI above C5 likely to require intubation

 visual and manual inspection of entire spine should

raise suspicion for flexion distraction injuries of

 examine face and scalp for evidence of direct trauma

 inspect for angular or rotational deformities in the holding

position of the patient's head

the midline or paraspinal tissues

patient predicts low probability of significant cervical injury.

 perform careful neurologic exam

•less radiation expsosure with reduced CT

look for subtle

 multiple spinal mets

 unresectable lesions in major organs

 SCI (complete or incomplete)

 aggressive CA: lung, osteosarcoma, pancreas

 Key sensory points:

B Incomplete Sensory but not motor function is preserved below the

C Incomplete Motor function is preserved below the neurological

D Incomplete Motor function is preserved below the neurological

E Normal Motor and sensory function is normal

Key muscles: L2 = iliopsoas; L3 = quadriceps; L4 = Tib ant; L5 = EHL; S1 = gastrosoleus

Trauma protocols with CT scans of chest, abd.

Obtunded patients require further skeletal

MRI – soft tissue imaging:

Surgical vs. Non-surgical treatment

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