Spinal trauma


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Spinal trauma

  1. 1. Spinal Trauma BY DR. SHAHERYAR AZIZ
  2. 2. Introduction • Annually 15,000 permanent spinal cord injuries • Commonly men 16–30 years old • Mechanism of Injury – – – – Vehicle crashes: 48% Falls: 21% Penetrating trauma: 15% Sports injury: 14% • 25% of all spinal cord injuries occur from improper handling of the spine and patient after injury. – ASSUME based upon MOI that patients have a spinal injury. – MANAGE ALL spinal injuries with immediate and continued care. • Best form of care is public safety and prevention programs.
  3. 3. Functional anatomy • Function • Skeletal support structure • Major portion of axial skeleton • Protective container for spinal cord • Vertebral Body • Major weight-bearing component • Anterior to other vertebrae components
  4. 4. Functional anatomy • The lumbar and low thoracic vertebrae are larger and wider. • The spinous processes are more horizontal. • Thoracolumber junction is more susceptible to injury because there is a fulcrum of increased motion. • Cauda equina begins at L1-L2. Lesions below L1 have a better prognosis as nerve roots , not cord are affected.
  5. 5. Bony anatomy
  6. 6. Bony anatomy
  7. 7. Bony anatomy
  8. 8. Discs
  9. 9. Ligaments
  10. 10. Spinal Meninges • Layers • Dura mater • Arachnoid • Pia mater • Cover entire spinal cord and peripheral nerve roots that exit • CSF fills the subarachnoid space • Exchange of nutrients and waste products • Absorbs shocks of sudden movement
  11. 11. Spinal Meninges
  12. 12. Spinal Cord Function Transmits sensory input from body to the brain Conducts motor impulses from brain to muscles and organs Reflex Center • Intercepts sensory signals and initiates a reflex signal Growth Fetus • Entire cord fills entire spinal foramen Adult – The lower tip of the spinal cord (conus medullaris) is usually at the level of the L1 vertebra. – Spinal nerves below this level comprise the cauda equina.
  13. 13. Subdivision of ANS – Parasympathetic, “Feed and Breed” • Controls rest and regeneration • Peripheral nerve roots from the sacral and cranial nerves • Major Functions – Slows heart rate – Increases digestive system activity – Plays a role in sexual stimulation – Sympathetic, “Fight or Flight” • Increases metabolic rate • Branches from nerves in the thoracic and lumbar regions • Major Functions – Decreases organ and digestive system activity » Vasoconstriction – Release of epinephrine and norepinephrine » Reduces venous blood volume » Increases peripheral vascular resistance – Increases heart rate – Increases cardiac output
  14. 14. • • • • • Upper Motor Neurons UMN Originate in cerebral cortex Project downward Result in skeletal muscle movement • Injury = SPASTIC paralysis • Lower Motor Neurons • LMN • Originate at each vertebral level • Project to specific parts of the body • Result in movement /sensation • Injury = FLACCID paralysis .
  15. 15. Spinal Nerves – 31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve roots – – – – – 8 cervical 12 Thoracic 5 Lumbar 5 Sacral 1 Coccygeal Sensory & motor functions Travel through intervertebral foramina  Each pair has 2 dorsal and 2 ventral roots Ventral roots: motor impulses from
  16. 16. Dermatomes • Dermatomes – Topographical region of the body surface innervated by one nerve root Key locations are :-
  17. 17. Dermatomes
  18. 18. Myotomes • Muscle and tissue of the body innervated by spinal nerve roots • • • • • • • • • • C5 C6 C7 C8 T1 L2 L3 L4 L5 S1 Flex Elbows (biceps , brachialis) Wrist extensors (extensor carpi radialis longus , brevis) Extend Elbow (triceps) Finger flexors (flexor digitorum profundus to the middle fingure) Small finger abductors (abductor digiti minimi) Hip Flexion (iliopsoas) Knee Extension (quadriceps) Ankle Dorsiflexion (tibialis anterior) Long toe extensors (extensor hallucis longus) Ankle planterflexors (gastrocnemius , soleus)
  19. 19. Myotomes
  20. 20. Mechanisms of Spinal Injury – Extremes of Motion Hyperextension: • Common in the neck • Anterior ligaments and disc may be damaged. Hyperflexion: • 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 column Shear
  21. 21. 3-column concept • The 3-column concept of the spine as defined by Denis is widely used as the conceptual framework for diagnosing acute overt spinal instability. • The anterior column consists of the anterior vertebral body (usually anterior twothirds), the anterior annulus, and the anterior longitudinal ligament. • The middle column refers to the posterior wall of the vertebral body, the posterior annulus, and the posterior longitudinal ligament. • The posterior column refers to the posterior ligamentous complex that connects adjacent neural arches, consisting of facet capsules, ligamentum flavum, interspinous ligament, and supraspinous ligament. • Failure of two or more columns generally results in instability.
  22. 22. . • 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.
  23. 23. . • In this context, a simple compression wedge fracture occurs due to failure of the anterior column with preservation of the middle column (stable). • On the other hand, a burst fracture occurs due to compression failure of both anterior and middle columns (usually unstable), often resulting in bone retropulsion into spinal canal. • A seat-belt type injury is attributed to distraction failure of the posterior and middle columns with hinging of an intact anterior column (unstable). • Fracture-dislocations involve failure of all 3 columns and are considered highly unstable.
  24. 24. Compressed vertebral fracture
  25. 25. Burst fracture
  26. 26. Spinal Cord Injury – Concussion • Similar to cerebral concussion • Temporary and transient disruption of cord function – Contusion • Bruising of the cord • Tissue damage, vascular leakage, and swelling – Compression • Secondary to: – – – – Displacement of the vertebrae Herniation of intervertebral disk Displacement of vertebral bone fragment Swelling from adjacent tissue – Laceration • Causes – Bony fragments driven into the vertebral foramen – Cord may be stretched to the point of tearing – Hemorrhage • Associated with contusion, laceration, or stretching
  27. 27. Symptoms and Signs Neurologic function Above the injury Below the injury • intact. 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 (eg, long bone fractures) or whose level of consciousness is altered by intoxicants or head injury may not complain of pain.
  28. 28. 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 • .
  29. 29. Conus medullaris & cauda equina
  30. 30. Conus Medullaris Syndrome Cauda Equina Syndrome Presentatio Sudden and bilateral n Gradual and unilateral Reflexes Knee jerks preserved but ankle jerks affected Both ankle and knee jerks affected Radicular pain Less severe More severe Low back pain More Less Sensory symptoms and signs Numbness tends to be more localized to perianal area; Numbness tends to be more localized to saddle area; symmetrical and bilateral; sensory dissociation occurs asymmetrical, may be unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris Motor strength Typically symmetric, hyperreflexic distal paresis of lower limbs that is less marked; fasciculations may be present Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common Impotence Frequent Less frequent; erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate Sphincter Urinary retention and atonic anal sphincter cause dysfunction overflow urinary incontinence and fecal incontinence; Urinary retention; tends to present late in course of disease
  31. 31. 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.
  32. 32. Incomplete cord injury: • 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 ) – Anterior Cord Syndrome • Flexion Compression. • Loss of motor function and sensation of pain, light touch, and temperature below injury site • Retain positional, and vibration sensation • Poor prognosis
  33. 33. – Central Cord Syndrome(age > 50) • Hyperextension injuries. • Motor and sensory loss affecting upper extremities more. • Fair prognosis
  34. 34. – 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
  35. 35. . • 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
  36. 36. Spinal Shock Temporary insult to the cord Affects body below the level of injury Diaphragmatic breathing Flaccid limbs Warm periphery Decr. Pain sensation Reduced reflexis Erection Urinary retention Decr. BP + Decr. Pluse rate = neurogenic Decr. Body temp. Return of bulbocavernosus reflex = end of spinal shock
  37. 37. • Neurogenic Shock – Signs and Symptoms • • • • • . Bradycardia Hypotension Cool, moist, and pale skin above the injury Warm, dry, and flushed skin below the injury Male: priapism • Autonomic Hyperreflexia Syndrome – Associated with the body’s response of the effects of spinal shock – Commonly associated with injuries at or above T-6 – Presentation • • • • • Sudden hypertension Bradycardia Pounding headache Blurred vision Sweating and flushing of skin above the point of injury
  38. 38. Grading of Spinal Cord Injury
  39. 39. Spinal Injury Impairment Scale American Spinal Injury Association Level Impairment A = Complete No motor or sensory function, including in the sacral segments S4–S5 B = Incomplete Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4—S5 C = Incomplete Motor function is preserved below the neurologic level, 1 and > ⁄2 of key muscles below neurologic level have a muscle grade < 3 D = Incomplete Motor function is preserved below the neurologic level, 1 and at least ⁄2 of key muscles below the neurologic level have a muscle grade > 3 E = Normal Motor and sensory function are normal
  40. 40. Management of the Spinal Injury Patient Objectives • • • • Preserve neurological function. Relieve reversible nerve or cord compression. Stabilize the spine. Rehabilitate the the patient.
  41. 41. DO NO HARM An important goal is to prevent secondary injury to the spine or spinal cord.
  42. 42. Prehospital care • An important goal is to prevent secondary injury to the spine or spinal cord. In unstable injuries, flexion or extension of • • • • • • the spine can contuse or transect the cord. Which can result in paraplegia, quadriplegia, or even death from spinal injury. Immobilize spine immediately. A rigid collar should be used to immobilize the cervical spine. Patients with thoracic or lumbar spine injuries should be shifted by logroll technique on a flat ,firm padded back board in supine position. Transfer to a trauma center Immediately. Pre hospital medical care should be directed at avoiding hypoxia and hypotension, both of which can further stress the injured cord.
  43. 43. LOGROLL Spinal trauma
  44. 44. Emergency department management • ABCs • Intubation if needed. • Spinal s stabilization. • secondary survey. • History – major accident , unconscious pt, fall from height , jerk to neck , head injury , facial injury. • Logroll – look for bruising , palpate for step and tenderness. • Look for associated injuries, such as brain, thoracic, or abdominal injuries. • Imaging; x-rays , CT , MRI. • repeated neurologic examination helps determine the presence of deficits its progression /resolution. • Hypotension and bradycardia may indicate neurogenic shock. • Maintain the systolic blood pressure at a value of at least 90 mm Hg with a heart rate of 60-100 beats per minute. • Bradycardia may be treated by the use of atropine. • Attempt to maintain urine output at a minimum of 30 mL/h. If all of the above parameters are difficult to maintain, consider support with inotropic agents. • These patients are also at risk for hypothermia and should be warmed to maintain a core temperature of at least 96°F. Place a Foley catheter to help with voiding.
  45. 45. . – Fluid Challenge • Isotonic solution: 20 mL/kg – 250 mL initially – Monitor response and repeat as needed – Dopamine • 2–20 mcg/kg/min titrated to blood pressure – Atropine • 0.5–1.0 mg q 3–5 min (maximum of 2.0 mg) – Steroids (Methylprednisolone) • Reduce swelling and pressure on cord • Begin steroid therapy within 8 hours of the injury. • The initial dose of methylprednisolone is 30 mg/kg administered over 15 minutes. • Start an infusion for the maintenance dose of 5.4 mg/kg/h at the beginning of the first hour and continue it through the 23rd hour. .
  46. 46. Thoracolumber injury classification & severity score • • • • • • • • • • • • • • • • • • • Fracture Mechanism points Compression fracture 1 Burst fracture 2 Translation/ rotation 3 Distraction 4 Neurological involvement Intact 0 Nerve root 2 Cord , conus medullaris , incomplete 3 Cord , conus medullaris , complete 2 Cauda equina 3 Posterior ligamentous complex intregity Intact 0 Injury suspected / indeterminate 2 Injured 3 Score< or equal to 3 non operative treatment Score > or equal to 5 operative treatment Score = 4 non operative/operative . (depend upon comorbid / other injuries)
  47. 47. Management With no neurological deficit: • If stable-pain relief , collar or brace. • If unstable-reduce and hold secure until bone / ligaments heal with surgery or traction. With complete sensory or motor loss: • Usually an unstable injury • Only consider conservative management for high thoracic injuries. • Early operative stabilization to help with nursing , prevent spinal deformity and pain. • Speeds up rehab. With incomplete neurological loss: • Stable injury-conservative bed rest , brace. • Unstable injury-early reduction and stabilization.
  48. 48. Surgical therapy • The goals of operative treatment are to decompress the spinal cord canal and to stabilize the disrupted vertebral column. • Three basic approaches are used for surgical management of the thoracolumbar spine: • (1) the posterior approach, (2) the posterolateral approach, and (3) the anterior approach. • Selection of the best approach is guided by the anatomy of the fracture and the location of spinal canal encroachment. • 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 rods, (3) cage, and (4) the Z-plate anterior thoracolumbar plating system. Each has different advantages and disadvantages.
  49. 49. complicatons Highest morbidity in first 2 weeks Most common cause of morbidity and motility are:  Respiratory insufficiency  Paralytic ileus  Urological complications.  GI bleeds  Pressure sores  Joint contractures  psychological
  50. 50. . .