Spinal Injuries


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  • This provides the biological rationale for early treatment of patients with acute SCI
  • Wide assortment.
  • Spinal Injuries

    1. 1.  11,500 cases peryear in US 1994: 207,000SCI patients 2.6% of alladmitted traumaSumma 1999, Burnley 1993, Lasfargues 1995
    2. 2.  #1 : Male teenagers and young adults Relative increase in 60-70 y/o MVA (44.5%) Falls (18.1%) Violence (16.6%)Summa 1999
    3. 3.  Cervical 50-64% Thoracic 17-19% Lumbar (cauda equine)20-24%
    4. 4.  C1-C2 Facet Joints› Horizontal plane› Facilitates axial rotation Tectorial Membrane› Continuation of PLL› Major occip- cervicalstabilizer› Secondary restraint forextension of occiput onatlas Alar LigamentsNetter’s Anatomy
    5. 5.  Lateral mass: Consists of ipsilateralsup/inf. facets Upward inclination of ~ 400 Facet joint complex resistsanterior translation androtation Vertebral artery Traverses foramen in TP Does not traverse C7Netter’s Anatomy
    6. 6.  Ribs and sternum limitthoracic spinemovement; increasestability Spinal cord takes upthe majority of thecanal space Facet joints in coronalplane
    7. 7.  Lordotic sagittalalignment (20-600) Significant (F/E)motion at each level Biplanar facet joints L2 -L5: Cauda EquinaNetter’s Anatomy
    8. 8. FG Fasc. Gracilis (Sensory,lower part of cord,Proprioceptive, Deep pain,Vibration, Ipsilateral)FC Fasc. Cuneatus (Sensory,Upper part of cord,Proprioceptive, Deep pain,Vibration Ipsilateral)PH Posterior Horn (Sensory cellbodies)AH Anterior Horn (Motor CellBodies)
    9. 9. LCS Lateral Corticospinal Tract(Crossed Pyramidal Upper MotorNeurons to ipsi AH)ACST Anterior Corticospinal Tract(Direct Pyramidal go to contra AH)PSCT ASCT Spinocerebellar TractsLST Lateral Spinothalamic Tract(Sensory, Pain and Temp: cell bodiesin contra PH)AST Anterior Spinothalamic Tract.(Sensory, Touch: cell bodies incontra PH)
    10. 10.  Exits through intervertebral foramen C1 exits between skull and atlas C2 to C7 exit above corresponding vertebrae C8 exits below C7, above T1 Below T1; all nerves exit below correspondingnumbered vertebral pedicle
    11. 11.  Spinal nerves that have exited from the cord L1-L5: Nerve cell bodies lie in the cord behind T11-T12 S1-S5: Nerve cell bodies line within the region ofthe conus medullaris Cauda equina nerves are more like peripheralnerves  withstand trauma better than CNS Damage to this region causes LMN signs
    12. 12.  Primary mechanical insult Rapid compression due to bone displacementfrom burst or dislocation Distraction *** Shear *** Penetration Primary injury leads to cascade ofsecondary injury mechanisms*** Portends poor prognosis !!!
    13. 13.  Vascular changes› Diminished blood flow› Hemorrhage› Vasospasm› Thrombosis Electrolyte shifts Free radical production Inflammatory cascade
    14. 14.  Final pathway is neuron death by: Cell necrosis with structural dissolution Apoptosis: chemical trigger initiates process thatremoves non-functioning neurons but also killsnormal neurons in zone of injury
    15. 15.  Aggressive field resuscitation› Maintain systemic BP› Maintain optimal oxygenation Steroids› NASCIS-2 8 hour window› NASCIS-3 < 3 hrs---24 hrs;3-8 hrs---48 hrs. 30mg/kg bolus then 5.4mg/kg/hr Surgical decompression? Timing ?
    16. 16.  Complete Cervical tetraplegia Thoracic and lumbar paraplegia Incomplete syndromes Anterior cord Central cord Brown-Sequard Posterior cord Conus medullaris
    17. 17.  Definition No motor or sensory function more than threesegments below the neurological level of injury There is absence of sacral sparing
    18. 18.  Absent limbfunction Ventilatordependence C4 level may bevent independent
    19. 19.  C5 deltoids, biceps C6 biceps, wristextension C7 wrist extension,triceps C8 functional grasp T1 intrinsic hand fct45
    20. 20.  Better respiratoryand trunk controlwith injury at morecaudal levels Thoracolumbarmost commonL1T1212L1
    21. 21.  L2 hip flexion L3/4 kneeextension L4 footdorsiflexion L5 EHL S1gastrocsoleusL2L2
    22. 22.  Indicates somecontinuity of long tractfibers Sacral structures aremost peripheral in bothposterior columns andlateral corticospinaltracts Continued function ofsacral LMNs in conusSkeletal Trauma
    23. 23.  Perianal sensation(S4-S5)dermatome Voluntary externalanal contraction Great toe flexoractivitySkeletal Trauma
    24. 24.  Affects the anterior 2/3 of cord Preserves the posterior column:proprioception, vibratory sensation May be due to persistent retropulsed boneor disc material/ mechanical insult Vascular component
    25. 25.  Loss of all motorand sensory belowinjured level Deep pressuresensation only Poor prognosis formotor recovery
    26. 26.  Older patients with preexisting spondylosis MOI: Hyperextension injury: fall, whiplash Spinal cord pinched by osteophytesanteriorly and the underlying hypertrophicligamentum flavum posteriorly; leads tosignificant injury to the “central portion” ofthe cord
    27. 27.  Best prognosis amongcommon patterns Upper extremity > lowerextremity involvement Distal > proximal Earliest and greatestrecovery in legs followed bybladder Hand dexterity often slow toreturn, full recovery variable
    28. 28.  Results from functionalhemisection of cord,projectile or penetratingwound Loss of ipsilateral motor Loss of contralateral pain,temperature, and lighttouch sensation 75% regain independentambulation 80% recover bowel andbladder function
    29. 29.  Rare Loss ofproprioception Maintainambulation but relyon visual input
    30. 30.  Direct injury to conus region (L1-L2) Presents as mixed lesion of cord and nerveroot damage Bowel, bladder, and sexual dysfunction Injury to CM can disrupt thebulbocavernosus reflex arc Therefore, the absence of a bulbocavernosusreflex unreliable indicator of spinal shock in thisclinical setting
    31. 31. Modified From: Lockhart RD; Hamilton GF; Fyfe FW.Anatomy of the Human Body. JB Lippincott Company
    32. 32.  Lower motor neuronlesion (not cord) Sacral segmentsmore affected thanlumbar Saddle anesthesiawith incontinence Lumbar sparing
    33. 33.  Common mechanism for central cord injury inelderly—hyperextension with a spondylolyticneck MRI findings impressive SCI protocol followed by observation untilrecovery plateaus Treatment : same as central cord syndrome.
    34. 34. Be aware of the clinical triad of neurological injury and concomitant lamina fracture with burst pattern (Cammisa, 1989)---trappedroots
    35. 35.  Decompression rarely ofbenefit except forINTRA-CANAL BULLET ATTHE T12 TO L5 LEVELS withincomplete injury(better motor recovery than non-operative) Fractures usually stable,despite “3-column” injury
    36. 36.  More favorable prognosis than cord injuries In c-spine injuries: frequently see completecord injury with varying levels of root injury Good chance of recovery of one level Recovery dependent on level of injury
    37. 37.  ATLS guidelines: A-B-C’s Examine for head, neck, or back trauma –need to logroll Paradoxical diaphragmatic breathing Priapism Neurogenic shock: hypotension andbradycardia Loss of sympathetic tone
    38. 38.  Log roll !!!!! Palpate Tenderness Gap/ Step-off Crepitus
    39. 39.  Motor: 0-5 Sensory Rectal exam: sacral sparing? DTRs: LMN function Spinal reflexes: UMN function
    40. 40.  Biceps C5 Brachioradialis C6 Triceps C7 Quadriceps L4 Gastroc-soleus S1
    41. 41.  Perianal/perineal sensation Rectal tone Big toe flexion Implies partial structural continuity of whitematter long tracts May be only evidence of incompleteinjuryhigher chance of recovery Essential to check and document
    42. 42.  Bulbocavernosusreflex: Pull glans or pressclitoris  analcontraction (int.sphincter) aroundgloved finger Absence is indicatorof spinal shockSkeletal Trauma
    43. 43.  Scapulohumeral reflex (C3) Tap on spine of scapula =>abd and elev arm Hoffman’s Inverted Radial Reflex Tap BR =>finger flexion (C6 root) Superficial abdomenal Cremaster Crossed adductor response Tap Medial Fem Condyle =>add contra leg
    44. 44.  Temporary loss of all or most spinal reflexactivity below level of injury Lasts around 24 hours (max 48 hrs) Ends when bulbocavernosus reflex and/oranal wink returns An injury cannot be considered completeuntil resolution of spinal shock
    45. 45.  Neurologic level ofinjury (NLI)› Most caudal level withbilateral normal motorand sensory function Complete/Inc› Importance of sacrallevels Zone of partialpreservation
    46. 46. A Complete:B Incomplete:C Incomplete:D Incomplete:E Normal:No motor or sensory below lesionSensory only below lesion to S4-5Preserved motor below lesion, keymuscle strength < 3Preserved motor below lesion, keymuscle strength > 3Normal motor and sensory belowlesion -ASIA 1992
    47. 47.  X-rays CT MRI MRA
    48. 48.  Lateral C-spine in trauma room› Must include down to C7-T1› Swimmer’s view or pull-down if necessary› Single most important radiographic examination C-spine series› AP, Open mouth (dens) T-L-S spine films as indicated (one spinefracture mandates full spine radiographicevaluation)› T-L junction: 50% of injuries occur at T11-L1
    49. 49.  Lordosis Unreliable sign of injury Prevertebral softtissues Unreliable No agreed uponmeasure 6 mm at C3 22 mm at C6
    50. 50.  Anterior spinal line› Anterior aspect of vertebralbody along ALL Posterior spinal line› Posterior aspect of vertebralbody along PLL Spinolaminar line› Joins the anterior margins ofthe junction of the lamina andspinous processes Spinous process line› Joins tips of spinous processes
    51. 51. – Lateral masses of C1Lateral masses of C1should align overshould align overfacet joints of C2facet joints of C2– combined lateralcombined lateralmass displacementmass displacementover 7 mm suggestsover 7 mm suggeststransverse ligamenttransverse ligamenttear (Spence’s Rule)tear (Spence’s Rule)
    52. 52.  Injury suspected on plain films Better visualize fracture (specificity andsensitivity) Unable to adequately assess on plain films Sagittal and/or coronal reconstructions can behelpful (particularly at Oc.-cervical and C-Tjcts.) Fracture or soft tissue injury in the plane ofthe CT can be missed
    53. 53.  Invaluable for assessing cord and soft tissues R/O associated disc herniation ( facetdislocations) Hemorrhage vs edema in soft tissues ???? Ligamentous tears and facet capsule disruptionsvisualized with fat suppression May allow prognostic assessment of final motorfunction› Intrasubstance hematoma
    54. 54. T1 T2 GRE
    55. 55.  Roaf, 1960 – pure axial load or pure flexionleads to little posterior ligamentous injury Nagel, 1981 – 20 degrees of kyphosis or 10degrees lateral angulation impliesincompetence of PLL and posterior elements,thus inferring instability
    56. 56.  Panjabi, 1981 – it takes sectioning of PLL andposterior annulus to destabilize a motionsegment with the addition of facet capsuleand interspinous ligament disruption James et al, ’94 – middle column offerslittle additional resistance to kyphosis withincreasing axial load
    57. 57.  The Issues Often difficult to diagnose Missed or delayed diagnosis can lead tocatastrophic neurologic disability No agreed upon protocol in the intoxicated,multiply-injured, or head-injured patient
    58. 58.  The Problems Unnecessary imaging? Should every patient with blunt trauma gets x-rays? Overzealous consultation When and who should ‘clear the c-spine’ ?? The Hard Collar Dilemma: Prolonged hard collar use leads to decubiti as well asneck pain
    59. 59.  Hoffman, Mower, et al., NEJM 2000 Multicenter study 34,069 patients with blunt trauma AP/Lat/Open Mouth on all patients 810 with positive x-rays Only 8 with false-negative x-rays Only 2 clinically significant
    60. 60.  Harris, Kronlage, et al. Spine 2000 Polytrauma, intoxicated, CHI patients IRB Protocol: Includes intra-op flex/ext withfluoro after all films read as normal Goal: Identify ligamentous injuries 3/ 153 (+) --- all required surgical stabilization
    61. 61.  Criteria for clinical clearance› No posterior midline tenderness› Full pain-free active ROM› No focal neurologic deficit› Normal level of alertness› No evidence of intoxication› No ‘distracting injury’
    62. 62.  If x-rays negative, but patient c/o neck pain,active flexion/extension x-rays when able.Rarely helpful in acute setting If neurologic deficit attributable to neckinjury, immediate MRI Controversy over the polytrauma orintoxicated patient remains EAST practice guidelines: trauma series and thincut axial CT through C1-2 CT of cervical –thoracic junction if poorvisualization on plain and swimmer’s
    63. 63.  15-30% incid. uni-/bilat Neuro intact: MRI priorto reduction attempt Neuro injured:Reduction prior to MRI Neuro unknown: MRIfirstAttempt reduction withoutMRI ONLY if able toaccurately monitorneurologic examthroughout process
    64. 64.  Experimental evidence Clinical evidence Non-operative Operative
    65. 65.  Numerous studies Classic: Tarlov 1954 Delamarter 1995 Dimar 1999 Experimental models: Balloons, clips, cables,spacers Beagles, rabbits, rats
    66. 66.  Severity of SCI dependent on: Force of compression Duration of compression Displacement, canal narrowing Surgical decompression does attenuate thedeleterious effects of acute SCI Persistent compression is a potentially reversibleform of secondary injury
    67. 67.  Most studies uncontrolled and retrospectiveanalyses Spontaneous recovery unpredictable, butgenerally occurs Timing to reduction is important Most dramatic benefit in bilateral jumpedfacets
    68. 68.  Surgical benefit must be weighed againstlimited non-operative benefit Numerous studies, almost exclusivelyretrospective Timing: early, late, and later
    69. 69.  The only prospective randomized trial 62 patients with cervical SCI 34 “Early” (< 72 hrs) surgery 28 Late (> 5 days) surgery ASIA assessment No difference in neurological outcome
    70. 70.  Most studies retrospective with historicalcontrols No clear consensus on timing No statistical evidence that surgicaldecompression influences neurologic outcome
    71. 71.  Tator et al 1999 Retrospective, multicenter (36) Examined use and timing of surgery inacute SCI 9 month period 1994 to 1995 All within 24 hours of injury 16 to 75 years old Non-penetrating trauma
    72. 72.  585 patients Complete SCI in 57.8% Traction 47% Surgery 65.4% < 24 hrs: 23.5% 25-48hrs: 15.8% 48-96hrs: 19% > 5 days: 41.7%
    73. 73.  C-spine vs. T-L spine Partial vs. complete› Spinal shock Definition of early surgery Role of steroids Type of decompression› traction vs. anterior vs. posterior High energy vs. low energy Associated injuries
    74. 74. There is strongexperimental evidencein animals to indicate: Decompressive surgeryof the spinal cordimproves recoveryafter SCI Earlier surgery yieldsmore improvement
    75. 75. There is strongexperimentalevidence thatsuggests earlydecompression (<6-8hrs) leads to a higherlikelihood ofneurological recovery.
    76. 76. Extrapolating animaldata to clinicalpractice may be aleap, but this datacomprises themajority of currentscientific evidence.
    77. 77. The sole prospectiverandomized studyconcluded that there isno difference betweenearly (<72 hrs) and late(> 5 days) surgicaldecompression withrespect to neurologicalrecovery.Vaccaro, et al. Spine 1997