Anatomy of the Cord and Cauda
*Spinal cord from foramen magnum to L1Conus at L1 for bowel and bladder (nervi
eriganties S1-S5)*L1 to S1 roots start innervation of lower
extremities*Thoracic blood supply to the cord starts
at T10-T12 (artery of Adamkowitz)*Lumbar blood supply is abundant
Physiological Anatomy of the Thoracic Spine
Facets lie in the frontal plane- allowing rotation
Ribs resist rotation and add stiffness in lateral rotation
Kyphosis of the T spine loads the anterior column
Lower 2 vertebra have floating ribs and no costotransverse articulations
Canal size in thoracic spine relatively small
Physiological Anatomy of the Lumbar Spine
Large discs allow more ROMFacets prevent rotation
Spinal canal widerLordosis loads the facets
Thoracolumbar JunctionThoracic spine stiffer in flexion (ribs) than lumbar
spine (stress riser)Lowest 2 thoracic vertebra have less extrinsic
stability secondary to changes in facet orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to stabilize, therefore less rotational resistance)
In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into lordosis leaving the transition vertebra exposed to pure compression
Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2 vertebra at the thoracolumbar junction
Mechanisms of InjuryHow much energy was imparted into the
individual (fall from height vs fall from level skiing vs ejection from car)
What was the loading force (impact onto buttocks vs impact onto flexed neck vs impact from object)
What was the force trajectory (beam impact vs restrained MVA vs collision with tree)
What was the quality of the tissue of the recipient to resist force (young adult vs senior/ preexisting pathology)
CAUSES OF SCI
Patient History
Loss of consciousnessLoss of motor strength (temp or
present)Sensory changes (temp or present)
Incontinence (at scene vs current)Localized pain to other areas
Dyspnea (pneumothorax)Past medical history
Patient Examination
ABCs first, then trauma examinationMotor strength L1-S1(for suspected
thoracolumbar injury)Sensory C4-S3
Reflexes (hyperreflexia asso. with preexisting myelopathy)
Rectal exam (sensory, tone and contraction) (missed conus injury)
Bulbocavernosis (if necessary)
STAGESStage of spinal shock (Flaccid Stage)
sensation and motor power localized below the vertical height of the lesion are lost. This stage lasts for 2 to 3 weeks in humans, and hours to days in other animals.
Stage of recovery (spastic stage)after a period typically ranging from 2 to 3
weeks of injury, the nerves partially recover, and the return of segmental reflexes produce paraplegia-in-flexion.
.
SYMPTOMS
The vertical location of the injury
In general, injuries that are higher in our spinal cord produce more paralysis .
The severity of the injury.(T S section)
Spinal cord injuries are classified as partial or complete, depending on how much of the cord width is damaged .
Treatment of Neurologic Injury
Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours
Only for central injuries- not peripheral nerve injuries (conus is central injury)
Mutiple Spinal Injuries
3 patternsWatch out for
distracting injuries10% of patients
can have other spinal injuries
Severity of trauma- splenic/ liver and vessel injury
Classification System
Holdsworth 2 column theoryDenis 3 column theory
Classification of Injuries Simple Compression (1-2 column injury)
Stable burst (2-3 column injury)Unstable burst (3 column injury)
Flexion distraction (2 nonconjoined columns)Chance (3 column failure all in tension)
Fracture dislocation (3 column injury)Pure Dislocation (rare) (3 column injury)
Pathological (any and all)Insufficiency (any and all)
Multiple contiguous fractures (nly 1-2 columns)
Compression Fractures
Only anterior column injuryMiddle? and post. OK
Ant. column less than 30%No more than 10 deg kyphosis
No neuro injury
Flexion distractionEasy to miss-
may look benignAnterior column
> 50% crushedMiddle column
mainly intactSignificant
spinous process widening
Unstable
Stable Burst
Both ant and middle column involvement
Minimal kyphosisNo neuro
involvementNo laminar
fracture
Unstable Burst
3 column involvement
Possible neuro involvement
Severe communition
Significant pedicle widening
Look for laminar fracture (asso. with root entrapment)
Chance FracturesOld “Seatbelt injuries”
Center of rotation is anterior to ALL
May be “bony” chance or purely ligamentous
Normally neuro intact “Bony” stable,
ligamentous unstable even though all are 3 column injuries
Fracture Dislocations
Translation in lower lumbar spine may be developmental (only L3-S1 spondylolysthesis)
Always abnormal in thoracic spine (ribs fix)
UnstableNormally- neuro deficit
Can be hidden at mid thoracic spine
3 column injury
Pathological Fractures
Normally in patient with history of CA
May be hard to distinguish from insufficiency or osteoporosis fracture
May be multiple levelsFracture out of
proportion to force of trauma
Suspicion calls for MRIand ?Bone scan
Insufficiency Osteoporosis Fractures
Normally in elderly females
Osteopenia/malaciaBones have “washed
out” appearance Minimal force vectors
Multiple levels (normally)
Kyphosis greater than 70 degrees may need surgery
?Vertebroplasty treatment
So how do you read the films?
Look at alignment of vertebraOn AP- measure pedicle distance and look
for both SP splaying and laminar fracturesMeasure kyphosis from intact endplates
Measure anterior and middle column heightLook for retropulsion
High index of suspicion for other fractures
Look at alignment
Look at how the anterior and posterior aspects of the body line up
Spinous Process Splaying
Indicative of either chance (stable) or flexion distraction (unstable) injury
Laminar Split
Associated with burst or flex-distraction fractures
Look on exam for root injuries (they become entrapped in lamina)
Possible association with dural tear
Measure Kyphosis
Measure from closest intact endplates
Measure Ant. and Middle Column Heights
Compare with vertebra above and below
Measure pedicle distances
Compare to vertebra adjacent to injured one
Anterior Column Fx Treatment Simple compressions can be placed in a Jewett or TLSO off the shelf brace and discharged from the ED or office as long as pain is controlled, fracture is stable with new standing x-rays in brace and they don’t have an ileus. Cannot treat fractures above T6 without cervical extension
Stable Bursts and Lateral Compression Fractures Admit- pain mgmt and
neuro checksBrace management -
Off the shelf TLSO for simple compressions greater than 30% and lateral compressions, Custom TLSO for unusual body habitis, severe bursts and pts that need stability testing. CASH for insufficiency Fxs
Complications from Fracture Pneumothorax (thoracic Fxs with asso rib Fxs)/
Ileus (30-60%)Splenic, liver and vessel injury (mechanism of
injury)DVT/PE
DecubitisUTI
PneumoniaRenal failure (hydronephrosis from cauda
equina involvement)
Stress Testing
Fracture that may be unstable
Bed rest until ambulance arrives
X Rays supine/ 45deg/ 90 deg/ upright
Stop if neuro involvement, sig. Pain increase or sig. Increased kyphosis
45 degrees vs upright
Surgical Indications
Neurological InvolvementFlexion distraction injury
Greater than 50% canal compromise with >15 degrees kyphosis
>25 degrees kyphosisFailure of stress testing
(severe pain, angulation above 25 degrees, neuro symptoms)
Fracture dislocationsSoft tissue “chance” fractures
Time to healing
Most non-surgical fractures heal within 12 weeks
Back support with braces(types)on whenever .patient upright
When healed- 4 weeks of PT for deconditioning
Residuals of barometric sensitive discomfort and occasionally problems with lifting
10 % may need to go on to surgery from instability pain
NURSING BEDS
Clinitron Bed Tilt Bed
ROTAREST BED
Thank You