Spinal injuries

Epidemiology

Incidence 2-5/100,000

about 10% will result in quadriplegia or paraplegia .

50% affects the cervical region

Adolescent and young adults males are the mostaffected.

Most are a consequence of road traffic accidents

Mechanisms of injuries Vertebral body fractureDisc herniationDisplacement of post. wall of thee vertebral body

Tearing of interspinous ligaments . Disruption of post. Ligament .

Tearing of Ant. Long. Lig. Separation of vertebral bodies .Avulsion of upper vertebral body from disc.

Associated with unilateral facet dislocation .

Cervical spine:

Flexion & flexion rotation injuries

Compression injuries

hyperextention

Thoracolumbar spine :

Flexion & flexion rotation injuries

Compression injuries

hyperextention

Flexion injury

Extension injury

The Three- Column TheoryWhen describing and diagnosing spinal fractures , spine surgeons divide the

spinal column into 3 sections :

Ant. Column >> ant. Long. Ligament + ant. One half of the vertebral body, disc, annulus.

Middle column >> Post. Long. Lig. + post. Half of the vertebral body, disc, annulus.

Post. Column >> facet joints, ligamentum flavum , post elements and the interconnecting lig.

Types of Fractures Seat belt

fractures

Wedge fracture

Burst

dislocation

Stable and Unstable Fractures :

Generally , a fracture is considered Stable if only the ant. Column is involved, as in most of wedged fractures.

Wheen the ant. And middle columns are involved the fracture may be considered more unstable.

When all three columns are involved the fracture is considered by definition Unstable.

Types of Fracture Column Affected Stable Vs. Unstable

Wedge fracture Ant. Only STABLE

Burst fracture Ant. And Middle UNSTABLE

Fracture / dislocation injuries

Ant. MiddlePost.

UNSTABLE

Seat belt fractures Ant.MiddlePost.

UNSTABLE

Whiplash injury

Whiplash Injury ..Traumatic injury to the soft tissue structures in the region of the cervical spine

(including ligaments, muscles , intervertebal discs…. ) due to hyperflexionhyperextension or rotational injury to the neck in he absence of fractures , dislocations.

Clinical grading of WAD severity

Grade Description

0 No complaints , no signs

1 Neck pain or stiffness or tenderness , no signs

2 Above symptoms with reduced range of motion or point of tenderness.

3 Above symptoms with weakness , sensory deficit , or absent deep tendon reflexes .

4 Above symptoms with fracture or dislocation.

WIP

LASH

Grade 1 : Pts with NL mental status and physical exam don’t require plain radiographs on presntation

Grade 2,3 : C- spine x rays , special imaging aren’t indicated.

Grade 3,4 : Should be managed a suspected spinal cord injury .

Recommendation Grade 1 Grade 2 Grade 3

Range of motion exercises Should be started immediately for all

Encourage early return to regular activities

immed ASAP

Cervical collars and rest No not> 72 hrs in not> 96 hrs

Passive modality therapies : heat,ice,massage,TENS, ultrasound,acupuncture

No Optional if symptoms last > 3 wks

Medication : optional use of NSIADS and non narcotic analgesics

No Yes Yes . Limited narcotics are neededoccasionally

Surgery No No Only for progressive neurological deficit or

persisting arm pain

Not recommended : cervical pillows and soft collars , bed rest , spray and stretch exercises , muscle relaxant med. ,intra-articular intrathecal or trigger point steriodinjection

Completeness of lesion ..

Incomplete lesions : any residual motor or sensory fxn more than 3 segments below the level of injury.

- Sacral sparing ; sensation around the anus, voluntary rectal sphincter contraction , or voluntary toe flexion

- an injury does not qualify as incomplete with preserved sacral reflexes alone .

Complete lesion : NO preservation of any motor and/or sensory fxn more than 3 segments below the level of the injury. ( the persistence of a

complete spinal cord injury beyond 24 hrs indicates that no distal fxn will recover . Only 3% will recover within 24 hrs . )

Spinal Shock …. ** Transient loss of all neurological function ( including segmental and

polysynaptic reflex activity and autonomic fxn) below the level of SCI > flaccid paralysis and areflexia lasting varying periods ( as minimal of 3-4 days or up to 6-8 wks or sometimes permanently ) , the resolution of which yields thee anticipated spasticity below the level of the lesion .

Incomplete lesions

Spinal tracts

Ant. Spinal cord syndrome

Compression of the ant. Aspect of cord > leads to the damage of corticospinal an spinothalamic tracts > motor paralysis below level + loss of pain an temp. and touch but with preservation of light touch , propriocption and position sensation.

Central spinal cord syndrome

Usually due to hyperextension of cervical spine . The damage is located centrally with the most severe injury to the more centrally lying cervical tracts which supplying Uls.

Disproportionately greater weakness in UL in comparison with the LL below the level of injury .

Brown – Sequard syndrome

Hemidisection of spinal cord .

Ipsilateral paralysis below the level

Loss of pain and temp. and touch contralaterally

Loss of position sence , proprioception ipsilaterally

Complete lesions

The most severe consequence of spinal trauma is complete transverse myelopathy in which all neurological function is absent below the level of the lesion, causing either paraplegia or quadriplegia, depending on the level.

There will also be impairment of autonomic function including bladder and bowel.

MOTOR DEFICIT Injuries to the spinal cord will cause upper motor neuron

paralysis characterized by loss of voluntary function Increased muscle tone and hyperreflexia.

Injuries to the lumbar spine causing cauda equinainjuries result in lower motor neuron paralysis characterized by reduced muscle tone, wasting and loss of reflexes.

Combination of upper and lower motor neurone lesions result from a thoracolumbar injury involving the conus medullaris and cauda equina.

SENSORY DEFICIT

In complete lesions the afferent long tracts carrying the various sensory modalities are interrupted at the level of the lesion, abolishing sensory appreciation of pain, temperature, touch, position and tactile discrimination below the lesion .

Occasionally there is a level of abnormally increased sensation, hyperaesthesia and hyperalgesia at or just below the lesion (sensory level).

AUTONOMIC DEFICIT

Vasomotor control: cervical and high thoracic lesions above the sympathetic outflow at T5 may cause hypotension. Interruption of the sympathetic splanchnic vasomotor control will initially cause a severe postural. hypotension as a result of impaired venous return.

Temp. control : the patient with complete spinal lesion will not have satisfactory thermal regulation as there will be impairment of the autonomic mechanisms for vasoconstriction and vasodilatation .

SPLANCHNIC DISTURBANCES

Impairment in bladder and bowel control

Management

Aims of Management :

- Prevention of further injury to spinal cord .

- Reduction and stabilization of bony injuries .

- Prevention of complications .

- Rehabilitation .

Initial treatment

Caution in turning and lifting the patient. Spine flexion should be avoided . A temporary collar should be applied if the injury is to cervical spine.

Hypotension and hypoventilation immediately following an acute traumatic SC injury may not be life threatening but may increase the extent of neurological impariment. Respiratory insufficiency may require oxygen therapy and ventilatory assistance.

Loss of sympathetic tone may result in peripheral vasodilatation with peripheral vascular pooling and hypotension. Treatment: intravascular volume expanders, alpha adrenergic stimulators, IV atropine, and occasionally the use of a transvenous pacemaker.

Spinal patients are poikilothermic and will tend to assume the temperature of the environment. Body temperature must be preserved in cold weather and the patient must not be overheated in warm weather.

NG tube to avoid problems associated with vomiting due to gastric stasis and paralytic ileus.

Urinary catheter, although intermittent catheterization may become preferable later

Prophylaxis for DVT with low dose heparin or LMWH, or stockings on the lower limbs

Radiological investigations

• x-ray

• CT.

• MRI

• Dynamic x-ray

1 - Progression of neurological deficit

2 - Patients with partial neurological injury, who fail to improve should have further radiological assessment. Surgery should be considered if this shows persisting extrinsic compression of the spinal cord within the canal (particularly from herniated cervical disc), a depressed fractured lamina or an osteophytic bar, although removal of the compression may not result in any neurological improvement .

3 – An open injury from a gunshot or stab wound should be explored to remove foreign particles , elevate bone spicules and if possible repair he dura .

4 – Most common indication is to stabilize the spine

Indications for surgical interventions :