Spinal Trauma

Stable vs. Unstable Injuries

Stable Injuries Vertebral components won’t be displaced by normal movement. An undamaged spinal cord is not in danger. There is no development of incapacitating deformity or pain.

Unstable Injuries Further displacement of the injury may occur. Loss of 50% of vertebral height. Angulation of thoracolumbar junction of > 20 degrees. Failure of at least 2 of Denis’s 3 columns. Compression fracture of three sequential vertebrae can lead to post

traumatic kyphosis.

Types of Spinal Cord Injury

The primary Injury When the skeletal structures fail to dissipate the energy of the

primary mechanical insult. Results in direct energy transfer to neuronal elements. ▪ Flexion▪ Extension▪ Axial Loading▪ Rotation or traction▪ Compression of the Cord

Secondary Injury Hemorrhage, oedema, and Ischemia secondary to the insult. Therapeutic strategies are directed at reducing secondary injury.

Mechanisms of Spinal Injury

Extremes of MotionHyperextension: ▪ Common in the neck▪ Anterior ligaments and disc may be damaged.

Hyper flexion:▪ If posterior ligament is intact , wedging of vertebral body occurs.If torn , may cause

subluxation.

Axial compression:▪ Causes burst fractures. Bony fragments may be pushed into spinal canal.

Flexion with rotation:▪ Causes dislocation with or without fracture.

Flexion with posterior distraction:▪ May disrupt middle and posterior columnShear

Spinal Cord Injuries

Symptoms and Signs

Neurologic function

Above the injury: intact.

Below the injury: absent or markedly diminished.

Specific manifestations depend on the exact level and whether cord injury

is complete or incomplete.

Vertebral injury typically is painful, but patients who are distracted by other

painful injuries (e.g., long bone fractures) or whose level of consciousness is

altered by intoxicants or head injury may not complain of pain.

Location of Injury Possible Effects

At or above C5 Respiratory paralysis and quadriplegia

Between C5&C6 Paralysis of legs, wrists, and hands; weakened shoulder abduction and elbow flexion; loss of brachioradialis reflex

C6-C7 Paralysis of legs, wrists, and hands, but shoulder movement and elbow flexion usually possible; loss of biceps jerk reflex

C7-C8 Paralysis of legs and hands

C8-T1 With transverse lesions, Horner's syndrome (ptosis, miotic pupils, facial anhidrosis), paralysis of legs

T1-T12 Paralysis of leg muscles above and below the knee

At T12 to L1 Paralysis below the knee

Cauda equina Hyporeflexic or areflexic paresis of the lower extremities, usually pain and hyperesthesia in the distribution of the nerve roots, and usually loss of bowel and bladder control

At S3 to S5 or conus medullaris at L1

Complete loss of bowel and bladder control

.

Basic Patient Assessment

Approach every patient in the same manner using Advanced Trauma Life Support Principles (ATLS).

Assume every trauma patient has a spinal injury until proven otherwise. All Assessment, Resuscitation and life saving procedures must be

performed with full spinal immobilization. Signs of spinal Injury:

Polytrauma patient Neurological Deficit Multiple Injuries Head Injuries Facial Injury High energy Injury Abdominal Bruising from a seatbelt.

Spinal Immobilization

Unconscious and pain-free patient. The Unconscious patient:

Full Assessment of the spine is difficult. Definitive clearance of the spine many not be possible initially. Maintain Spinal Immobilization until MRI rules out injury.

The Pain-free patient: There is no pain. Palpation of the spine is non-tender. Neurological examination is normal. There is pain free range of movement.

The mechanism and velocity of injury should be determined at an early stage.

Physical Examination

Initial Assessment Be aware that spinal injury may mask signs of intra-abdominal injury.

Identification of Shock Three types of Shock may occur in spinal trauma: ▪ Hypovolaemic Shock: Presents with hypotension, tachycardia, cold clammy

peripheries. Caused by hemorrhage; treated with appropriate fluid replacement. ▪ Neurogenic Shock: Hypotension w/ normal heart rate or bradycardia and

warm peripheries. Caused by unopposed vagal tone resulting from cervical spinal cord injury above the level of the sympathetic outflow (C7/T1).

▪ Spinal Shock: Characterized by paralysis, hypotonia, and areflexia. Lasts for only 24 hours. Assess patient neurologically. When it starts to resolve bulbocavernosus reflex returns.

Bulbocavernosus reflex

The bulbocavernosus reflex (BCR) or "Osinski reflex" is a polysynaptic reflex that is useful in testing for spinal shock and gaining information about the state of spinal cord injuries (SCI)

Spinal Examination

Spinal Examination Spine Log Roll must be performed to achieve proper

examination. Inspect and palpate entire spine. Swelling, tenderness, palpable steps or gaps suggest a

spinal injury. Note the presence of any wounds that might suggest

penetrating trauma.

Neurological Evaluation

American Spinal Injury Association neurological evaluation system is used. Motor Function assesses key muscle groups. Grade (0-5) Sensory Function assesses dermatomal map. (Pinprick and light touch) Score: 0-

2 Rectal examination:▪ Anal tone.▪ Voluntary anal contraction.▪ Perianal sensation.

What should be known after complete neurological examination? Presence or absence of neurological injury. Probable level of injury. Injury is complete or incomplete. Level of impairment.

ASIA neurological impairment scaleA Absent motor and sensory function.

B Sensory function present, motor function absent.

C Sensory function present, motor function present but not useful. (MRC Grade<3/5)

D Sensory function present, motor function useful. (MRC Grade≥3/5)

E Normal Function.

Complete Cord Injury

Transection leads to immediate, complete, flaccid paralysis (including loss of

anal sphincter tone), loss of all sensation and reflex activity, and autonomic

dysfunction below the level of the injury. High cervical injury (at or above C5) , causing

Respiratory insufficiency especially in patients with injuries at or above C3.

Bradycardia and hypotension (neurogenic shock) .

Arrhythmias and BP instability may develop.

Flaccid paralysis gradually changes over hours or days to spastic paralysis

with increased deep tendon reflexes due to loss of descending inhibition. Later, if the lumbosacral cord is intact, flexor muscle spasms appear and

autonomic reflexes return.

Incomplete Cord Transection

Partial motor and sensory loss occurs, and deep tendon reflexes may be exuberant. Rapid swelling of the cord results in total neurologic dysfunction resembling complete cord injury (spinal shock )

Central Cord Syndrome Brown-Sequard Syndrome Anterior Spinal syndrome Posterior Cord Syndrom Cauda Equina Syndrome

Anterior Cord Syndrome

Flexion Compression injuries to the cervical spine may damage anterior spinal artery cutting off blood to anterior 2/3rd of spinal cord. Loss of motor function and sensation of pain, light

touch, and temperature below injury site Retain positional, and vibration sensation Poor prognosis

Central Cord Syndrome

Hyperextension of the cord results in pinching of the cord in pre-existing degenerative narrowing od the spinal cord. Upper limbs and hands profoundly affected. Distal motor function in the legs usually spared. Fair Prognosis

Brown-Sequard’s Syndrome

Penetrating injury that affects one side of the cord Ipsilateral motor loss vibration and position sense. Contralateral pain and temperature sensation loss Best prognosis

Posterior Cord Syndrome

Least frequent syndrome Injury to the posterior (dorsal) columns Loss of proprioception Pain, temperature, sensation and motor function

below the level of the lesion remain intact

Cauda Equina Syndrome

Diagnostic Imaging

85% of significant spinal injuries will be seem on standard lateral cervical spine.

CT Scan should be obtained. Most Sensitive in spinal trauma. Complex patterns and fractures can be understood.

MRI Best at visualizing soft-tissue elements of the spine. Possible to view spinal cord hemorrhage, epidural and prevertebral

hematomas. Not good at assessing bony structures.

In spinal traumas radiographs and CT scans usually give sufficient information and MRI is not required.

Management of the Spinal Injury Patient

Objectives Preserve neurological function. Relieve reversible nerve or cord compression. Stabilize the spine. Rehabilitate the patient.

An important goal is to prevent secondary injury to the spine or spinal cord.

Surgical Approach

The goals of operative treatment are to decompress the spinal cord canal and to stabilize the disrupted vertebral column.

Also consider the need for stabilization procedures. Categories of procedures for spine stabilization

The 4 basic types of stabilization procedures are 1. posterior lumbar interspinous fusion, 2. posterior rods3. cage4. The Z-plate anterior thoracolumbar plating system. Each has different

advantages and disadvantages.