Anatomy of the Cord and Cauda
Spinal cord from foramen magnum to L1*
Conus at L1 for bowel and bladder (nervi
(eriganties ...
Physiological Anatomy of the
Thoracic Spine
Facets lie in the frontal plane- allowing rotation 
Ribs resist rotation and ...
Physiological Anatomy of the
Lumbar Spine
Large discs allow more ROM 
Facets prevent rotation 
Spinal canal wider 
Lord...
Thoracolumbar Junction
Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress
(riser
Lowest 2 thoracic vertebr...
Mechanisms of Injury
How much energy was imparted into the 
individual (fall from height vs fall from level
(skiing vs ej...
CAUSES OF SCI
Patient History
Loss of consciousness 
(Loss of motor strength (temp or present 
(Sensory changes (temp or present 
(In...
Patient Examination
ABCs first, then trauma examination 
Motor strength L1-S1(for suspected 
(thoracolumbar injury
Senso...
STAGES
(Stage of spinal shock (Flaccid Stage 
sensation and motor power localized below the 
vertical height of the lesi...
SYMPTOMS
The vertical location
of the injury
In general, injuries 
that are higher in
our spinal cord
produce more
. para...
Treatment of Neurologic
Injury
Methylprednisolone protocol (30 mg/kg 
loading and 5.4 mg/kg x 24 (or 48) hours
Only for c...
Mutiple Spinal Injuries
patterns 3 
Watch out for 
distracting injuries
of patients can 10% 
have other spinal
injuries...
Classification System
Holdsworth 2 column theory 
Denis 3 column theory 
Classification of Injuries
(Simple Compression (1-2 column injury 
(Stable burst (2-3 column injury 
(Unstable burst (3 ...
Compression Fractures
Only anterior column injury 
Middle? and post. OK 
Ant. column less than 30% 
No more than 10 deg...
Flexion distraction
Easy to miss- may 
look benign
Anterior column > 
50% crushed
Middle column 
mainly intact
Signific...
Stable Burst
Both ant and middle 
column involvement
Minimal kyphosis 
No neuro 
involvement
No laminar fracture 
Unstable Burst
column 3 
involvement
Possible neuro 
involvement
Severe communition 
Significant pedicle 
widening
Loo...
Chance Fractures
”Old “Seatbelt injuries 
Center of rotation is 
anterior to ALL
May be “bony” chance or 
purely ligame...
Fracture Dislocations
Translation in lower 
lumbar spine may be
developmental (only L3(S1 spondylolysthesis
Always abnorm...
Pathological Fractures
Normally in patient with
history of CA



May be hard to distinguish
from insufficiency or
osteopo...
Insufficiency Osteoporosis
Fractures
Normally in elderly females 
Osteopenia/malacia 
Bones have “washed out” 
appearan...
So how do you read the
?films

Look at alignment of vertebra 
On AP- measure pedicle distance and look for 
both SP spla...
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 entrappe...
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
fr...
Stable Bursts and Lateral
Compression Fractures
Admit- pain mgmt and 
neuro checks
Brace management -Off 
the shelf TLSO...
Complications from Fracture
(/Pneumothorax (thoracic Fxs with asso rib Fxs 
(Ileus (30-60% 
(Splenic, liver and vessel i...
Stress Testing
Fracture that may be 
unstable
Bed rest until ambulance
arrives
X Rays supine/ 45deg/ 90
deg/ upright
Stop...
degrees vs upright 45
Surgical Indications
Neurological Involvement 
Flexion distraction injury 
Greater than 50% canal compromise 
with >15 ...
Time to healing
Most non-surgical fractures heal within 12 weeks 
Back support with braces(types)on whenever 
.patient u...
NURSING BEDS
Clinitron Bed 

Tilt Bed 
ROTAREST BED
Thank You
Spinal cord injuries spinalfractures thoracolumbar fracture
Spinal cord injuries spinalfractures thoracolumbar fracture
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Spinal cord injuries spinalfractures thoracolumbar fracture

  1. 1. Anatomy of the Cord and Cauda Spinal cord from foramen magnum to L1* Conus 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*
  2. 2. 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 
  3. 3. Physiological Anatomy of the Lumbar Spine Large discs allow more ROM  Facets prevent rotation  Spinal canal wider  Lordosis loads the facets 
  4. 4. Thoracolumbar Junction Thoracic 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  
  5. 5. Mechanisms of Injury How 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
  6. 6. CAUSES OF SCI
  7. 7. Patient History Loss of consciousness  (Loss 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 
  8. 8. Patient Examination ABCs first, then trauma examination  Motor 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 
  9. 9. STAGES (Stage 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 .
  10. 10. 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
  11. 11. 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
  12. 12. Mutiple Spinal Injuries patterns 3  Watch out for  distracting injuries of patients can 10%  have other spinal injuries Severity of trauma-  splenic/ liver and vessel injury
  13. 13. Classification System Holdsworth 2 column theory  Denis 3 column theory 
  14. 14. 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 
  15. 15. Compression Fractures Only anterior column injury  Middle? and post. OK  Ant. column less than 30%  No more than 10 deg kyphosis  No neuro injury 
  16. 16. Flexion distraction Easy to miss- may  look benign Anterior column >  50% crushed Middle column  mainly intact Significant spinous  process widening Unstable 
  17. 17. Stable Burst Both ant and middle  column involvement Minimal kyphosis  No neuro  involvement No laminar fracture 
  18. 18. Unstable Burst column 3  involvement Possible neuro  involvement Severe communition  Significant pedicle  widening Look for laminar  fracture (asso. with ( root entrapment
  19. 19. Chance Fractures ”Old “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
  20. 20. Fracture Dislocations Translation in lower  lumbar spine may be developmental (only L3(S1 spondylolysthesis Always abnormal in  (thoracic spine (ribs fix Unstable  Normally- neuro deficit  Can be hidden at mid  thoracic spine column injury 3 
  21. 21. Pathological Fractures Normally in patient with history of CA  May be hard to distinguish from insufficiency or osteoporosis fracture May be multiple levels   Fracture out of proportion to force of trauma Suspicion calls for MRIand ? Bone scan  
  22. 22. Insufficiency Osteoporosis Fractures Normally in elderly females  Osteopenia/malacia  Bones have “washed out”  appearance Minimal force vectors  (Multiple levels (normally  Kyphosis greater than 70  degrees may need surgery Vertebroplasty treatment? 
  23. 23. So how do you read the ?films Look at alignment of vertebra  On AP- measure pedicle distance and look for  both SP splaying and laminar fractures Measure kyphosis from intact endplates  Measure anterior and middle column height  Look for retropulsion  High index of suspicion for other fractures 
  24. 24. Look at alignment Look at how the  anterior and posterior aspects of the body line up
  25. 25. Spinous Process Splaying Indicative of either  chance (stable) or flexion distraction (unstable) injury
  26. 26. 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
  27. 27. Measure Kyphosis Measure from closest  intact endplates
  28. 28. Measure Ant. and Middle Column Heights Compare with  vertebra above and below
  29. 29. Measure pedicle distances Compare to vertebra  adjacent to injured one
  30. 30. 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
  31. 31. Stable Bursts and Lateral Compression Fractures Admit- pain mgmt and  neuro checks Brace 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
  32. 32. Complications from Fracture (/Pneumothorax (thoracic Fxs with asso rib Fxs  (Ileus (30-60%  (Splenic, liver and vessel injury (mechanism of injury DVT/PE  Decubitis  UTI  Pneumonia  Renal failure (hydronephrosis from cauda equina  (involvement 
  33. 33. 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  
  34. 34. degrees vs upright 45
  35. 35. Surgical Indications Neurological Involvement  Flexion distraction injury  Greater than 50% canal compromise  with >15 degrees kyphosis degrees kyphosis 25<  Failure of stress testing (severe pain,  angulation above 25 degrees, neuro (symptoms Fracture dislocations  Soft tissue “chance” fractures 
  36. 36. 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 may need to go on to surgery from % 10  instability pain
  37. 37. NURSING BEDS Clinitron Bed  Tilt Bed 
  38. 38. ROTAREST BED
  39. 39. Thank You

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