Topic- Spinal Injuries

• MODERATORS = DR. AK CHAURASIA(MCh)

DR. ID CHAURASIA (MCh)
DR. RAJNEESH GAUR(MCh)

PRESENTER = DR. MOHIT SHARMA (RSO-3)

 ANATOMY OF THE SPINE AND
SPINAL CORD
The vertebral column is composed of a series of
motion segments. A motion segment consists of two
adjacent vertebrae, their intervertebral disc and
ligamentous restraints.
LIGAMENTOUS SPINAL RESTRAINTS
• The cervicothoracic and thoracolumbar
junctions are transitional zones where the
spine changes from a mobile section (cervical
and lumbar) to a more fixed one (thoracic).
These two areas are common sites of injury.
 Spinal stability
• Spinal stability is the ability of the spine to withstand physiological
loads with acceptable pain, avoiding progressive deformity or
neurological deficit.
• The spine can be divided into three columns: anterior, middle and
posterior.
• If two or more columns of the spine are injured, it is considered
unstable.
 Spinal neuroanatomy
• The spinal cord extends from the foramen magnum to the
L1/ L2 level, where it ends as the conus medullaris in
adults (lower in children) (Figure 30.8). Below this level lies
the cauda equina. Figure 30.9 illustrates a cross-section of
the spinal cord.
 SPINAL INJURIES
• The spine should initially be immobilised using full spinal
precautions, on the assumption that every trauma
patient has a spinal injury until proven otherwise
• The mechanism and velocity of injury should
be determined at an early stage.
• A check for the presence of spinal pain should
be made.
• The onset and duration of neurological
symptoms should also be recorded.
 PHYSICAL EXAMINATION
Initial assessment
• The primary survey always takes precedence,
followed by a careful systems examination
paying particular attention to the abdomen
and chest.
 Spinal examination
• The overlying skin should be inspected (e.g. for
possible penetrating wounds) and the entire spine
must be palpated.
• A formal spinal log roll must be performed to
achieve this.
• Significant swelling, tenderness, palpable steps or
gaps suggest a spinal injury.
• A rectal examination should be undertaken to
assess anal tone and perianal sensation.
• Seatbelt marks on the abdomen and chest must be
noted, as these suggest a high-energy accident.
 Neurological examination
• The American Spinal Injury Association (ASIA) neurological
evaluation system is an internationally accepted method of
neurological evaluation.
• Motor function is assessed using the Medical Research
Council (MRC) grading system (0–5) in key muscle groups. A
motor score can then be calculated (maximum 100).
• Sensory function (light touch and pin prick) is assessed using
the dermatomal map. A total sensory score is then calculated.
• Rectal examination is performed to assess anal tone,
voluntary anal contraction and perianal sensation.
 Level of neurological impairment
• The extent of spinal cord injury is defined by the
American Spinal Injury Association (ASIA) Impairment
Scale (modifed from the Frankel classifcation):

● A: complete spinal cord injury;

● B: sensation present, motor absent;
● C: sensation present, motor present but not useful
(MRC grade <3/5);
● D: sensation present, motor useful (MRC grade ≥3/5);
● E: normal function.
 DIAGNOSTIC IMAGING
• Plain radiographs

• Anteroposterior and lateral radiographs of the

whole cervical spine, and open mouth views.

• If a spinal fracture is identifed then further

imaging of the whole spine is required because
there is a 15% incidence of a further spinal
fracture.
 A system for evaluation of the lateral
cervical spine radiograph
1. Assess prevertebral soft-tissue swelling
2. Assess sagittal alignment using three
imaginary lines
3. Assess for instability :
a. 3.5 mm of sagittal translation;
b. sagittal angulation of >11° (compared with
the adjacent level).
 Computed tomography
• Computed tomography (CT) scanning remains
the gold standard in spinal trauma
• Indicated for patients with suspected or visible
injuries on plain radiographs.
• Patients undergoing a head CT scan for head
injury should also have a cervical screening CT.
• CT of the chest and abdomen are also
performed in case of polytrauma.
 Magnetic resonance imaging
• MRI is indicated in all patients with neurological deficit
• And for assessment of ligamentous structures
 MANAGEMENT OF SPINAL AND SPINAL
CORD INJURIES
• Spinal realignment
In cases of cervical spine subluxation or
dislocation, skeletal traction is necessary to
achieve anatomical realignment. This is done
using skull tongs
Open reduction and stabilisation using internal
fixation is also required
• Decompression of the neural elements
Realignment of the spine and correction of the
spinal deformity achieves an indirect
decompression.
Direct decompression of the neural elements
indicated if there are bone fragments causing
residual compression or a significant
haematoma.
Stabilisation
• The indication for operative intervention is
influenced by the injury pattern, level of pain,
degree of instability and the presence of a
neurological deficit.
• The only absolute indication for surgery in
spinal trauma is deteriorating neurological
function.
• Corticosteroids
Corticosteroids are no longer indicated in acute
spinal cord injury because of a lack of evidence
to support efficacy.
Steroids do have a role in non-traumatic spinal
cord compression, e.g. malignant spinal cord
compression.
 SPECIFIC SPINAL INJURIES
Upper cervical spine (skull–C2)
• Occipital condyle fracture
This is a relatively stable injury often associated with head
injuries and is best treated in a hard collar for 6–8 weeks.

• Occipitoatlantal dislocation
This injury is usually caused by high-energy trauma and is
often fatal.
The dislocation may be anterior, posterior or vertical.
Powers’ ratio is used to assess skull translation. Treatment
is with a halo brace or occipitocervical fxation.
 POWER’S RATIO
Tip of basion to the posterior arch of C1 divided by distance from opisthion to the anterior
arch of C1
 Atlas fracture (Jefferson fracture)
• Fracture of the C1 ring is associated with axial loading of the
cervical spine and may be stable or unstable. Associated
transverse ligament rupture may occur. Most are treated
non-operatively in a cervical collar or halo brace.
 Atlantoaxial instability
• This is defined as non-physiological movement
between C1 and C2.
• It can be translational or rotatory and resolves
either spontaneously or with traction followed
by a cervical collar.
• Isolated, traumatic transverse ligament rupture
leading to C1/2 instability is uncommon and is
treated with posterior C1/2 fusion.
(a) Atlantoaxial
subluxation
(b) C1/2 posterior fusion
using C1 lateral mass and
C2 pedicle screws.
 Odontoid fractures
• There are three types of odontoid peg fracture.
• Neurological injury is rare.
• The majority of acute injuries are treated non-
operatively in a hard collar or halo jacket for 3 months.
• Internal fixation with an anterior compression screw is
indicated for displaced fractures, and a posterior C1/2
fusion is considered in cases of non-union.
• In the elderly, treatment in a soft collar should be
considered on the basis that a relatively stable
pseudarthrosis will occur.
(a) Type II odontoid (b) treated with an
fracture (arrow) anterior compression
screw.
 Traumatic spondylolisthesis of the axis
(Hangman’s fracture)
• This is a traumatic spondylolisthesis of C2 on C3. There are four
types with varying degrees of instability. Those with significant
displacement or associated facet dislocation are treated
operatively, usually with posterior stabilisation.
 Subaxial cervical spine (C3–C7)
• The pattern of lower cervical spine injury depends on the
mechanism of trauma.
• These include compression fractures (hyperfexion), burst
fractures (axial compression), facet subluxation/dislocation
injuries (distraction–fexion), teardrop fractures
(hyperextension) and fracture of posterior elements.
• The more severe injuries may have an associated spinal cord
injury.
• Operative intervention may be required to decompress the
spinal cord and to stabilise the spine with internal fxation.
(a) Cervical burst (b) treated with
fracture with anterior
spinal cord decompression and
contusion reconstruction.
 Thoracic and thoracolumbar fractures
• The system developed by the AO
(Arbeitsgemeinschaft für Osteosynthesefragen)
can be used to classify these fractures.
• There are three main injury types, A, B and C, with
increasing instability and risk of neurological injury.
• Type A = vertebral body compression fractures.
• Type B = involve distraction of the anterior or
posterior elements
• Type C =are rotational and often coexist with type
A or type B injuries
Thoracolumbar spinal fractures (T11–L2)

• The thoracolumbar junction is prone to injury. This can

vary from a minor wedge fracture to spinal dislocation.
• Burst fractures are comminuted fractures of the vertebral
body. They are characterised by widening of the distance
between the pedicles and can be associated with
retropulsion of bone fragments into the spinal canal .
• The current treatment principles involve posterior
fixation.
• Chance fractures are flexion–distraction injuries of the
thoracolumbar junction and are classically associated with
the use of lap belts
 Lumbar spinal fractures (L3–S1)
• Most fractures of the lower lumbar spine can be
treated non-surgically because the incidence of
neurological injury is lower.
• The neural canal is more capacious at this level
(the spinal cord terminates at L1/L2).
• Owing to the lumbar lordosis, patients with
these injuries are less likely to develop a
kyphotic deformity than those with injuries at
the thoracolumbar junction.
 Complications associated with spinal cord
injury
Three categories of shock may occur in spinal
trauma –

Hypovolaemic shock = Hypotension with

tachycardia and cold clammy peripheries. This is
most often due to haemorrhage. It should be
treated with appropriate resuscitation.
 Neurogenic shock.

This presents with hypotension, a normal heart

rate or bradycardia and warm peripheries.
This is due to unopposed vagal tone resulting
from cervical spinal cord injury at or above the
level of sympathetic outflow (T5).
It should be treated with inotropic support, and
care should be taken to avoid fluid overload.
 Spinal shock.
• Spinal shock is a temporary physiological
disorganisation of spinal cord function that starts
within minutes following the injury.
• The length of effect is variable, but it can last 6
weeks or longer.
• It is characterised by paralysis, decreased tone and
hyporeflexia.
• Once it has resolved the bulbocavernosus refex
returns.
Pressure ulcers = Many are preventable. Patients
should be turned regularly on an appropriate
mattress to minimise the risk of skin breakdown.

Pain and spasticity = Neurogenic pain is common.

Once reflex activity returns following cord injury,
spasticity may occur and can be problematic.
Intrathecal infusion of baclofen may be required in
resistant cases.
 Autonomic dysreflexia
• This is a paroxysmal syndrome of
hypertension, hyperhidrosis (above the level
of injury), bradycardia, flushing and headache
in response to noxious visceral and other
stimuli.
• It is most commonly triggered by bladder
distension or rectal loading from faecal
impaction.
 Neurological deterioration
• Post-traumatic syringomyelia may occur in around
28% of patients with spinal cord injury up to 30 years
following injury.
• Approximately 30% of cases are symptomatic.
• Clinically, patients present with segmental pain at or
above the level of injury, sensory loss, progressive
asymmetrical weakness or increased spasticity.
• This warrants early MRI assessment. Expanding
cavities require neurosurgical intervention.
 Thromboembolic events
Deep vein thrombosis occurs in 30% of patients
with spinal cord injury.
Fatal pulmonary embolus is reported in 1–2% of
cases.
Thromboprophylaxis with compression stockings
and low-molecular-weight heparin is indicated,
provided there are no contraindications.
 Osteoporosis, heterotopic ossification and
contractures
• Disuse osteoporosis is an inevitable consequence of
spinal cord injury and fragility fractures may occur.
• Heterotopic ossification may affect the hips, knees,
shoulders and elbows.
• It occurs in 25% of patients with spinal cord injury.
Surgery is appropriate in selected cases.
• Soft-tissue contractures around joints may occur as a
result of spasticity but can be avoided by appropriate
physical therapy, positioning and splinting.
•Thank You