PG IN (MS ORTHO)
Gandhi medical college
~ 40 % of all spinal trauma is found in the
2-3 % of all polytrauma victims have associated
cervical spine injuries
~30,000 cervical spine injuries are documented
Most common site ---- cervical 60%,thoraco
lumbar junction 20%, thoracic15%, lumbo sacral
16% people will have non-contiguous spine
50% will have other skeletal or visceral injuries
2/3rd of this do not have neurolgical deficit
Most common missed severe injury
Commonly missed in
E T I O L O G Y
Most frequent cause motor vehicle crashes
Severity of injury –complete quadriplegia
A G E & S E X
Mean age is 32 yrs
Highest incidence-16-30 yrs
Male :female ratio 3:1
Elderly more likely to have SCI than young
more due to falls rather than violence &
Life expectancy decreases with severity
&age of pt
Least in ventilatory dependent pts
Greater who survive 1 yr after spinal injury
During 1 st yr cause of death are –
respiratory& cardiac cause
Mortlity decreased but life expectancy
Circulation // Cervical spine
Field intubation: Avoid head tilt / chin lift
Early identification of SCI ‗in the field‘ ---
Avoid hypotension and hypoxia
Disability---complete neuro exam
Motor/ sensory/ reflexes
Perineal sensory/ anal wink/ bulbocavern.
Fully disrobe and log roll
Direct palpation of spine, collar removed
A detailed history of the mechanism of injury is important, but frequently is
unobtainable at the initial examination.
suspected in any patient with a head injury or severe facial or scalp
In any patient with recent trauma, complaints of neck pain or spinal pain
should be considered indicative of a spinal injury until proved otherwise.
Other risk factors associated with spinal injury, , include an inability to
assess neck pain because of a secondary distracting injury,
abnormal neurological findings,
history of transient neurological symptoms,
physical signs of spinal trauma (e.g., ecchymosis and abrasions), unreliable
mental status also should be assessed
The head –
for lacerations and contusions and palpated for facial fractures.
The ear canals should be inspected to rule out leakage of spinal
fluid or blood behind the tympanic membrane, which is suggestive
of a skull fracture.
The spinous processes should be palpated from the upper cervical
to the lumbosacral region. A painful spinous process may indicate
a spinal injury.
Palpable defects in the interspinous ligaments may indicate
disruption of the supporting ligamentous complex.
• tenderness on palpation of the cervical spine should be considered indicative
of a spinal injury requiring collar immobilization.
• neck motion should not be evaluated until the spine is cleared. Neck motion
should be undertaken only after the patient reports no pain or tenderness during
examination of the neck.
•An assistant should hold the neck steady in a neutral position while it is being
palpated. The neck also should be held steady while the torso and the thoracic,
lumbar, and sacral spinal areas are exposed for inspection and palpation
•. Sensation to light touch should be documented comparing each spinal level.
Pinprick sensibility should be determined with a sterile needle if necessary
•. Motor strength should be examined sequentially.
• Deep tendon reflexes and pathological reflexes also should be checked.
• Motor and sensory evaluation of the rectum and perirectal area is mandatory.
• The patient should be evaluated for posturing. The elbows may be flexed if a
spinal cord injury causes loss of function below the biceps, or they may be
extended if the paralysis is higher.
• Penile erection and incontinence of the bowel or bladder suggest a significant
spinal injury. Quadriplegia is indicated by flaccid paralysis of the extremities.
•Initial blood pressure may be decreased without a compensatory increase in
pulse because of spinal cord shock.
• BRADYCARDIA OR EPISODES OF ASYSTOLE MAY BE THE ONLY FINDING OF
SIGNIFICANT INJURY TO THE AXIAL REGION OF THE CERVICAL SPINE.
•The chest, abdomen, and extremities should be examined for occult injuries.
•The spine should be protected during this initial assessment;
The patient's mental status and the level of consciousness should be determined
quickly, including pupillary size and reaction –G L A S G O W C O M A
S C A L E
Eyes Open Spontaneous 4
To sound 3
To pain 2
Best Verbal Response Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible words 2
Best Motor Response Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
performed with light touch, then pinpricks (using a sterile needle),
beginning at the head and neck and progressing distally, to
examine specific dermatome distributions
Important dermatome landmarks are the
nipple line (T4),
xiphoid process (T7),
inguinal region (T12, L1),
perineum and perianal region (S2, S3, and S4).
The skin should be marked where sensation is present before
proceeding to motor examination.
Evidence of sacral sensory sparing establishes the diagnosis of an
incomplete spinal cord injury.
The only area of sensation distal to an obvious cervical lesion in a
quadriplegic patient may be in the perianal region
M O TO R E X A M I N AT I O N
should be systematic, beginning with the upper extremities.
complete / incomplete spinal cord injuries /pure nerve root lesions.
A protruded cervical disc /unilateral dislocated facet may produce an
isolated nerve root paralysis.
key muscle groups and their corresponding nerve root levels
+/- of sacral motor sparing should be determined by voluntary rectal
sphincter / toe flexor contractions.
If voluntary contraction of the sacrally innervated muscles is present with
sacral sensation, the prognosis for recovery of motor function is good.
+ OF anal reflex without sacral sensation is consistent with a complete
Finally, reflexes should be documented.
Paralyzed patients usually are areflexic, and flexion withdrawal of the legs
to pinprick does not indicate voluntary motion. Hyperreflexia, clonus, and
pathological reflexes, such as a Babinsky reflex in the lower extremities or
a Hoffman sign in the upper extremities, indicate chronic spinal cord
compression. This may be @ the findings of a central cord syndrome.
K E Y M U S C L E G R O U P S
C5 ---Elbow flexors (biceps, brachialis)
C6--- Wrist extensors (extensor carpi radialis longus
C7-- Elbow extensors (triceps)
C8 ---Finger flexors (flexor digitorum profundus to
the middle finger)
T1 ---Small finger abductors (abductor digiti minimi)
L2 ---Hip flexors (iliopsoas)
L3--- Knee extensors (quadriceps)
L4 ---Ankle dorsiflexors (tibialis anterior)
L5 ---Long toe extensors (extensor hallucis longus)
S1 ----Ankle plantarflexors (gastrocnemius, soleus)
Although spinal shock generally resolves
within 24 hours, it may last longer. A positive
bulbocavernosus reflex /return of the anal
wink reflex indicates the end of spinal
If no motor or sensory function below the
level of injury can be documented when
spinal shock ends, a complete spinal cord
injury is present, and the prognosis is poor
for recovery of distal motor or sensory
American Spinal Injury Association Scale: Classification
of Spinal Cord Injuries According to the Level of
Grade Motor Score* Sensory Deficit*
A 0/5 Complete
B 0/5 Incomplete
C <3/5 Incomplete
D >3/5 Incomplete
E 5/5 None
SPINAL CORD INJURIES
Neurological level = most caudal
segment with normal sensori-motor
Complete SCI = absence of sensori-
motor function in the lowest sacral
Incomplete SCI = partial preservation of
sensory and/or motor below the defined
neurological level, includes the lowest
SPINAL CORD INJURIES
Neurogenic shock = immediate loss of
sympathetic tone after SCI. Loss of
vasomotor and cardiac innervation.
Clinically: hypotension w/out
Fluid resus.; may need vasopressor
Spinal shock = transient period of areflexia.
While in shock, unable to predict likelihood
of recovery . Rarely > 48 hours
CENTRAL CORD SYNDROME
destruction of the central area of the spinal cord, including
gray and white matter
centrally located arm tracts in the cortical spinal area are
the most severely affected, and the leg tracts are
affected to a lesser extent.
Generally, patients have a quadriparesis involving the upper
extremities to a greater degree than the lower. Sensory
sparing varies, but usually sacral pinprick sensation is
frequently show immediate partial recovery after being
placed in skeletal traction through skull tongs.
Prognosis varies, but more than 50% of patients have
return of bowel and bladder control, become ambulatory,
and have improved hand function.
usually results from a hyperextension injury in an older
individual with preexisting osteoarthritis of the spine.
The spinal cord is pinched between the vertebral body
anteriorly and the buckling ligamentum flavum
BROWN SEQUARD SYNDROME
is an injury to either half of the spinal cord
usually is the result of a unilateral laminar or pedicle fracture, penetrating
injury, / rotational injury resulting in a subluxation.
Ipsilateral loss of proprioception due to posterior column involvement.
Contralateral loss of pain and temperature due to involvement of lateral
Ipsilateral spastic weakness due to descending corticospinal tract
LMN signs at the level of lesion.
Prognosis for recovery is good, with significant neurological improvement often
ANTERIOR CORD SYNDROME
hyperflexion injury in which bone or disc
fragments compress the anterior spinal
artery and cord.
characterized by complete motor loss and
loss of pain and temperature discrimination
below the level of injury.
The posterior columns are spared to varying
degrees resulting in preservation of deep
touch, position sense, and vibratory
Prognosis is poor.
POSTERIOR CORD SYNDROME
Involve dorsal columns
Impaired position and vibration sense in LL
Tactile and postural hallucinations can occur.
Numbness or paresthesia are frequent complaints..
Positive rhomberg sign.
Positive lhermittes sign. es the dorsal columns of the spinal cord
Absent knee and ankle jerk (Areflexia, Hypotonia
CM: Lies opposite to vertebral bodies of T12 and L1.
Contributes to 25% of spinal cord injuries.
Caused by flexion distraction injuries and burst fractures.
Both UMN and LMN deficits occur.
Development of neurogenic bladder.
CONUS MEDULLARIS SYNDROME
CE: Begins at L2 disk space distal
to conus medullaris.
CE syndrome occurs due to:
Acute disk herniation
CAUDA EQUINA SYNDROME
Flaccid lower extremities.
Knee and ankle jerk absent.
Asymmetrical sensory loss
Loss of sensation around perineum, anus, genitals.
CAUDA EQUINA SYNDROME
Loss of bladder and bowel function.
CAUDA EQUINA SYNDROME
DDX: CONUS VS CAUDA
FEATURE CONUS MEDULARIS CAUDA EQUINA
PRESENTATION Sudden & Bilateral Gradual & Unilateral
REFLEXES Knee present, Ankle –
(If the epiconus is involved,
patellar reflex maybe
bulbocavernosus is spared)
Knee & Ankle –
Bulbocavernosus reflex is
absent in low CE (sacral)
RADICULAR PAIN Less severe More severe
LOW BACK ACHE More Less
FEATURE CONUS MEDULARIS CAUDA EQUINA
Numbness tends to be
more localized to
Sensory loss of pin
prick & temperature
sensation is spared.)
Numbness tends to be more
localized to saddle area;
asymmetrical, maybe 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.
FEATURE CONUS MEDULARIS CAUDA EQUINA
distal paresis of lower
limbs that is less marked;
fasciculations may be
Asymmetric areflexic paraplegia
that is more marked;
atrophy more common .
IMPOTENCE Frequent Less frequent; ED is common
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.
FEATURE CONUS MEDULARIS CAUDA EQUINA
Urinary retention and atonic
anal sphincter cause
incontinence and fecal
Tend to present early in
course of disease.
Tends to present late in course of
EMG Mostly normal lower
extremity with external
anal sphincter invlmnt
Multiple root level involvement;
sphincters may also be
OUTCOME Less favourable More Favourable
TO X-RAY OR NOT TO X-RAY
(a) midline pain or bony
tenderness, crepitus, or
(b) neurologic deficit;
(c) presence of distracting
(d) altered mental status
(e) complaint of
Plain films – Lateral, AP, and Odontoid
TO BE ADEQUATE: :
ALL 7 VERTEBRAE
SUP. ENDPLATE OF T1
this is main view
Where 90% lesions are
Predental Space should be
no more than 3 mm in adults
and 5 mm in children
Increased distance may
indicate fracture of odontoid
or transverse ligament injury
Should be uniform
Assess spaces between
the spinous processes
LATERAL VIEW: C1 AND C2
8mm, top normal
C1: Anterior and
C2: Dens, Harris‘
ring, body especially
ant/inf corner, pars
and posterior arch.
In an adult, upper
normal is 2.5mm.
Space is parallel or
narrow ―V‖ shape.
In a young child,
upper normal is
suspect jafferson #
PRE VERTEBRAL SOFT TISSUE
Nasopharyngeal space (C1) - 10 mm
Retropharyngeal space (C2-C4) - 5-7
Retrotracheal space (C5-C7) - 14
mm (children), 22 mm (adults)
Extremely variable and nonspecific
Contour is more important than
The laminar space is the distance from the
posterior aspect of the articular pillars (1)
to the spinolaminar line (2
indicate rotational injuries of the cervical spine
displacement in this line may
be an indication of subtle
injury/dislocation. A line (white
line in B) drawn through C1-3
spinolaminar lines (white dots
in A) should intercept the C2
spinolaminar line. A
displacement of the C2
spinolaminar line of more than
2 mm, compared with a line
drawn between the
spinolaminar lines of C1 and
C3, is abnormal
The normal AP diameter of the cervical
canal is stated to be 12 to 21 mm.
anteroposterior width of the canal with that
of the vertebral body. The normal ratio of
the spinal canal (white arrow) to the
vertebral body (black arrow) is 0.8 or more.
SYMMETRY OF PEDICLES
CONTOUR OF BODIES
HEIGHT OF DISC SPACES
CENTRAL POSITION OF SPINOUS PROCESSES
FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL
PLANE -- THUS NOT SEEN ON AP
IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR
PEDICLE FX WITH ROTATION IS LIKELY
should line up.
Disc space should be
Vertebral body height
should be uniform.
Check for oblique
ODONTOID VIEW/OPEN MOUTH VIEW
Adequacy: all of
the dens and
lateral borders of
C1 & C2
masses of C1 and
dens for lucent
A+B > 7mm indicates
rupture of transverse
Reverse Waters view is supplementary, to
see top half of dens ONLY.
May be helpful in
due to muscle
Should not be done
in acute setting
Rules: Patient must
be alert, awake, not
intoxicated, able to
sit or stand, able to
view to see C7-T1 in
lateral projection. NOT a
substitute for a bad
lateral. One arm must be
worsen a mechanical or
A state-of-the-art CT
sagittal reformat is
preferable: don’t need
to move patient and
imaging easier and
CT: SAGITTAL REFORMATTING
computer from axial
data: no additional
Uncertain plain radiographic findings
In presence of osseous injury by plain films to
provide details & aid in surgeryplanning
inadequate visualization by plain films
Localize foreign bodies& bone fragments in
Pts having high risk of spinal injury, fall from
height from 10 feet,closed head injury
Pts with neurologic findings,negative plain films,
negative non contrast CT where MRI is not
Gold standard for
cord, thecal sac,
nerve root and disc
Very good for
Fairly good for
fractures, but does
miss some. CT
MULTIPLE SPINAL #
If a spinal fracture
is identified at any
level, the entire
spine should be
lateral views to
absence of spinal
fractures at other
In pattern A,
the primary lesion occurs
between C5 and C7, with
secondary injuries at T12
or the lumbar spine.
In pattern B,
the primary injury occurs
at T2 and T4, with
secondary injuries in the
In pattern C,
the primary injury occurs
between T12 and L2, with
secondary injuries from L4
Active motion most painful
Cervical Sprain (Whiplash)
Passive and active motion painful
Muscle spasm and facet irritation
Brachial Plexus Stretch or Compression
Contusions to Throat
CERVICAL SPINE CURVATURE
Normal cervical spine
has lordotic curve
Increased lordotic curve
indicative of poor
posture and muscular
weakness or imbalance
Lessened lordotic curve
indicative of muscular
nerve root impingement
ASSOCIATED SOFT TISSUE INJURY
Carotid and vertebral artery injuries have
been found to be alarmingly frequent with
cervical spinal injuries. This injury is
associated with a small but potentially
devastating risk of stroke or death
Caused due to sudden deceleration injury
Sudden stopping of a moving vehicle
The head goes into hyperflexion and then
WHIPLASH CAN CAUSE
Rupture of interspinous ligaments in the
posterior side of c-spine
Unlocking of facet joints
Rupture of disc or fracture of vertebrae
Severe neck pain and stiffness
May present with quadreplegia
X-ray may be normal
M R I – may show the soft tissue injury and
hemorrhage below the longitudinal ligaments
May present with quadreplegia with out any
radiological changes – due to cord contusion
Anti – edema measures
Wait for the neurological recovery
C1 and C2: by anatomic location
C3 to T1: by mechanism of injury
(Modified from the classification of John
Harris, et al.)
Often fatal but in children survivable
complete disruption of all ligamentous relationships between the occiput
and the atlas
Death usually occurs immediately from stretching of the brainstem,
which can result in respiratory arresttation & Distraction
ICA & vertebral injuries are common
Fatal cases often show contusions in pons, medulla ,spinal cord
Neurological Deficits Confusing
Always severe retropharyngeal swelling
Distance from basion to odontoid < 12mm
The Power ratio is calculated by
dividing the distance between the
basion and the posterior C1 arch by
the distance between the opisthion
and the anterior C1 arch.
A ratio greater than 1 is suggestive
of an atlanto-occipital dislocation.
Harris measurements, also
known as the ―rule of twelve,‖
include the BAI (basion-axis
interval) and the BDI (basion-
dens interval). The BAI is the
measured distance between the
basion and a perpendicular line
drawn in relation to the posterior
vertebral body tangent line of
C2. The BDI is the measured
distance between the basion
and the tip of dens. Both
distances should normally be
stabilization with a plate-screw-rod construct
and fusion with iliac crest bone graft.
THE ATLAS AND THE AXIS
C1 and C2 injuries differ from the rest of the
cervical spine and are considered separately.
Although controversial, best to consider ALL
C1 and C2 injuries as UNSTABLE in the
acute trauma setting.
THE ATLAS: C1
Anterior arch fracture: extension, uncommon.
Posterior arch fracture: extension, more
JEFFERSON fracture: axial load, common
C1: ISOLATED ARCH FRACTURES
CAUTION: You may
be dealing with a
Jefferson fracture with
Best to CT all C1
Non operative if no
JEFFERSON FRACTURE: C1
Axial loading/burst #
Lateral view: anterior and
posterior arch fractures
OMO view: lateral
displacement of C1 lateral
The lateral masses of C1 and
C2 must be aligned on the
1-2mm of lateral displacement
on one side and an EQUAL
medial displacement on the
other is head rotation.
ANY other pattern: lateral
displacement on both sides or
lateral on one side, and none
on the other is abnormal.
cord injury in 15% cases
Classical Jefferson: 4
fractures, 2 ant./2 post.
Jefferson variants: 2 or 3
fractures, but at least 1
ant. & 1 post.
The distinction between
stable and unstable
Jefferson or burst
fractures is the integrity of
the transverse ligaments.
The transverse ligament is
disrupted in tension with
lateral displacement of the
fragment fragments, which
can lead to C1-C2
Stable Jefferson or burst fractures can be
treated nonoperatively in a rigid cervical
collar for 8 to 12 weeks.
Unstable fractures can be reduced in halo
traction, followed by placement in a halo vest
Surgery Posterior atlantoaxial stabilization
and fusion is an effective treatment of
residual C1-C2 instability
THE AXIS: C2
ANDERSON & D‘ALONZO CLASSIFICATION
1 fracture through the tip
Rigid cervical collar for 8 wks
Type 2 fracture through the base
Type 3 fracture through the base and body of axis
type I-hard cervical collar for eight weeks
Most nondisplaced type II fractures in young
patients are treated in halo vest
most nondisplaced type III fractures are
treated a hard cervical collar.
Displaced type II and III fractures in young
patients are first reduced using halo traction.
posterior C1-C2 stabilization and fusion in
those with neurological deficits
or pedicle fracture,
Cord injury in 15%.
LEVINE & EDWARDS CLASSIFIACTION
type I is a minimally or nondisplaced
with no evidence of translation or
angulation and thus no substantial
injury to the C2-C3 disc space.
both angulation and translation and
presumably occur from an
extensions mechanism. They incur
substantial injury to the C2-C3
interspace. In contrast,
type IIa fractures occur via a flexion
mechanism and are characterized by
marked angulation with minimal
Type III fractures include any C2 pars
fracture associated with a dislocation
rigid cervical orthosis
closed reduction with traction and position opposite direction
halo vest immobilization
follow for loss of reduction
reduction of facet dislocation with traction
early posterior open reduction and fixation using lateral mass
screw fixation of C2 and C3
C2 -C3 fusion after pre-op MRI
C2: EXTENSION TEARDROP
Avulsion by the
ligament of the
corner of the body.
Cord injury is low.
LOWER CERVICAL SPINE C3-C7
FERGUSON AND ALLEN
Based on position of neck at time of injury
and dominant force
2 column theory
everything anterior to PLL ant column
most patients have a combination of patterns
CF Stage 1: Blunting of the anterosuperior
vertebral body margin
CF Stage 2: Beak-appearance of the
anterosuperior vertebral body margin, a
sagittal vertebral body split may also be
CF Stage 3: Oblique primary fracture line
that extends from the anterior vertebral
body to the inferior endplate.
CF Stage 4: In addition to stage 3
features, posterior translation of the
upper vertebra measuring less than 3 mm
CF Stage 5: Posterior translation of the
upper vertebral measuring 3 mm or
greater, facet gapping, indicating anterior
and posterior ligamentous injury
COMPRESSION AND FLEXION
Level C4-5 and C5-6
compression of ant column and distraction of post
different stages with later stages having more post
involvement and displacement of vertebral body
MRI to evaluate post ligaments
intact - HALO sufficient
not - risk of late kyphotic deformity therefore
VC Stage 1: Central superior or
inferior endplate fracture
VC Stage 2: Superior and inferior
endplate fractures, sometimes with
vertebral body fracture lines that give
the appearance of a quadrangular
VC Stage 3: Vertebral body
comminution, with or without
retropulsion of fragments
(This has been by others as a burst-
type cervical fracture), with or without
kyphotic (late flexion type) or
translational (late extension type)
C6-7 most common
shortening of ant and post columns
stage 1 -
cupping of end plate with partial failure anteriorly and normal
stage 3 -
fragmentation and displacement of body ― burst‖
neurologic injury common with assoc post element fractures
anterior corpectomy and reconstruction for neuro recovery
plus post fusion to prevent kyphosis
explode the body.
All are very unstable
and cause cord
injury in 2/3 (except
There is usually an
element of flexion
On lateral, body is
end plate often
body contour is
On AP, body
fracture is vertical or
oblique and pedicles
CT more accurately
displays the fracture
pattern and the very
important degree of
narrowing of the
DF Stage 1: Facet subluxation,
gapping of the spinous process
ligaments, indicating failure of the
PLC, with or without some blunting
of anterosuperior vertebral body (like
CF stage 1)
DF Stage 2: Unilateral facet
dislocation, usually PLC is intact,
DF Stage 3: Bilateral facet
dislocations, 50% translation of
upper vertebral body on lower one
DF Stage 4: Close to 100%
translation of upper vertebral body
on lower one, apperance of a so-
called floating vertebra
Most common pattern
tensile failure and lengthening of post column with
possible compression of ant column
ant translation superior vertebra
25% facet subluxation
50% unilateral facet dislocation
> 50% bilateral dislocation
full body displacement
50-80% assoc acute disk herniation at level of
awake closed reduction has not shown worsening
of neuro deficit and should not undergo major delay
in reduction while waiting for MRI
MRI prerequisite to open reduction
Disk present ant cervical diskectomy prior to
Closed reduction initially max weight
non-operative treatment 64% late instability
open reduction and fusion
UID is not stable, as
capsule ligaments are
Cord injury is
uncommon, but root
injury is common,
Findings can be
subtle: less than 50%
CT: THIS IS A NORMAL FACET JOINT, NORMAL
CT: UID has
hamburger sign‖ of
CT is also more
BID, also called ―locked
facets‖ is anything but
locked. It is a severe 3
column injury that is
Cord is injured in 2/3.
Body is subluxed
anteriorly at least 50%.
CE Stage 1: Posterior arch fracture that may
be facet, pedicle, or lamina fracture, with or
without rotation that can result in mild
anterior translation. (These are more
commonly referred to as lateral mass
CE Stage 2: Bilateral lamina fractures, can be
CE Stage 3: Bilateral lamina, facet, pedicle
fractures without vertebral body
displacement. Although admittedly
“hypothetical… having not been
encountered” in their review, the injury may
be described as a floating lateral mass
CE Stage 4: As for CF stage 3, with partial
anterior vertebral body displacement
POSTERIOR ARCH FRACTURES
Plain films are insensitive,
CT is outstanding.
Isolated: pedicle, lateral
mass, lamina or spinous
Multiple fractures are
fractures cause free-
floating lateral mass.
May be additional element
of lateral bending.
Stability depends on what
DE Stage 1: Abnormal widening of the
disc space, may or may not be avulsion
fractures of the anterior vertebral body
margin, no posterior translation
DE Stage 2: DF stage 1 plus posterior
Cervical spine fractures are uncommon in
children. The overall incidence of spinal
fractures in pediatric trauma patients is <1%
In addition, the injury patterns are different,
with cranio-cervical junction injuries being
more prevalent in this group
CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF
ALL SPINE FRACTURES
BY AGE 8-10, NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES
PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL
VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE
DIFFERENCES IN MECHANISMS OF INJURY
INHERENTLY MORE MOBILE:
GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES
THICK CARTILAGINOUS ENDPLATES
INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL
SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4
HEAD DISPROPORTIONATELY LARGE
ANTERIOR ANGULATION OF
FOCAL KYPHOSIS OF MID-
DIFFERENT SOFT TISSUE
PEAD ANATOMIC VARIANTS
-NON TRAUMATIC INJURY
DEFINED BY PANG AND WILBERGER, 1982:
―Objective Signs Of Myelopathy As A Result Of
Trauma With No Evidence Of Fracture Or
Ligamentous Instability On Plain Xray And
FINDING OF FRACTURE, SUBLUXATION, OR
ABNORMAL INTERSEGMENTAL MOTION AT
LEVEL OF NEUROLOGICAL INJURY
EXCLUDES SCIWORA AS A DIAGNOSIS
EXPERIMENTALLY, OSTEOCARTILAGINOUS STRUCTURES IN SPINAL
COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL
CORD RUPTURES AFTER 1/4 INCH
ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED -
SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND
SCIWORA = Spinal Cord Injury Without
Children have vertebrae that can dislocate and
quickly relocate. Cord gets damaged but shows
an aligned vertebral column.
Cord can be transected or compressed.
THREE COLUMN THEORY OF
Spinal column divided into 3 columns;
Anterior column; The anterior longitudinal ligament,
anterior 2/3 of the body and disc.
Middle column; Posterior longitudinal ligament and
posterior 1/3 of body and disc.
posteriorcolumn; The posterior osseous arch and
Injury to one column is stable, two or three are unstable.
DOES IT WORK?
If two or three columns injured, lesion is
unstable: Works well for C3 to T1.
Does not work so well for C1-2, so consider
most or all injuries here unstable.
PANJABI AND WHITE: CLINICAL INSTABILITY IN THE
LOWER CERVICAL SPINE
Anterior elements Destroyed or Unable to Function 2
Posterior Elements Destroyed of Unable to Function2
Relative Sagittal Plane Translation > 3.5mm
Relative Sagittal Plane Rotation > 11deg
Positive Stretch Test
Medullary (Cord) Damage
PLAIN RADIOGRAPHY & CT -
Anterior translation of the vertebral body a distance >3.5
mm relative to the subjacent vertebra
▪ Vertebral body shows > 20 degrees of angulation
relative to the adjacent vertebra
▪ Vertebral body shows >11 degrees of angulation relative
to the adjacent vertebral body pairs
▪ Increase in atlantoaxial distance (>3 mm)
▪ Hangman fracture with >3 mm of fragment displacement
or >a 15-degree angle at the fracture site
▪ Hangman fracture with abnormal C2-3 disc space or
with C2-3 dislocation
▪ Anterior or posterior displacement of the C2
spinolaminar line of >2 mm relative to a line drawn
between the spinolaminar lines of C1 and C3
Basion-dental interval (BDI) >12 mm
▪ Basion-axial line interval (BAI) >12 mm
▪ Unilateral facet dislocation
▪ Bilateral facet dislocation
Widening of the uncovertebral joints
Sum of C1 lateral mass offset in excess of 7
mm (adding the amount of lateral displacement
of each C1 lateral mass)
▪ Odontoid fracture type I or II
▪ Occipital condyle fracture type III
rigid cervical orthosis- Philadelphia collar
unstable injury this is inadequate often and
cervical traction required
halo traction or gardner-wells tongs
1cm posterior to external auditory meatus and just
above the pinna
should be MRI compatible
10-15 pounds usually appropriate
post alignment xray and neuro exam
Injuries demonstrating angulation, rotation or
restore normal alignment therefore decompressing
the spinal canal and enhancing neuro recovery
preventing further injury
need neuro monitoring and radiography
awake, alert and cooperative patient to provide
traction, positioning and weights ( 10 pds head and 5
pds each level below) xray after new weight applied
maintain after with 10-15 lbs traction
In incomplete lesion, early stabilization
prevent repetitive injury of the spinal cord
and improve neurological outcome.
Delayed neurological deterioration--- 5%.
Early mobilization and rehabilitation.
Stabilization had benefit in all spinal injury
Immediate correction with external orthotic
device or operative fixation
External orthoses vs surgical intervention
Surgical stabilization better than external
Early stabilization better than late stabilization in
post-surgical neurological deterioration
NASCIS I,II,III---randomized, prospective,
Within 3 hours, MPSS 30mg/kg bolus +
5.4mg/kg/hr infusion for 24 hours.
During 3~8 hours, MPSS 30mg/kg bolus +
5.4mg/kg/hr infusion for 48 hours.
Effect of neurogenic improvement: suppress
inflammatory response and vasogenic edema.
SURGICAL DECOMPRESSION (1)
Cervical spinal cord injury----
During complete injury, no neurological
improvement in early or later decompression.
During incomplete injury, controversial in surgical
Laminectomy may result in neurological
Anterior cervical decompression may improve
function in incomplete quadriplegics.
SURGICAL DECOMPRESSION (2)
Experimental models-- rapid decompression
better than later intervention.
Human model— early reduction within 8 hours
brings significant recovery in one study; however,
some others against it.
Increased risk such as pulmonary morbidity
associates early surgery.
SURGICAL DECOMPRESSION (3)
Anterior approach is favored; posterior
laminectomy has no benefit and worse cord
As a consensus, the only accepted indication for
emergent surgical treatment is progressive
neurological deterioration--- such as fracture
displacement, epidural hematoma, spinal cord
edema or infarction.
TAKE HOME MESSAGE
IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO NOT
ACCEPT INADEQUATE ONE
KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS
DO NOT FORGET NONSKELETAL INJURIES:
LIGAMENTOUS INSTABILITY, AND SCIW0RA
If a spinal fracture is identified at any level, the entire spine
should be examined with anteroposterior and lateral views to
document the presence or absence of spinal fractures at other
DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE -
ALWAYS LEAVE IN A HARD COLLAR
Progressive neurological deficit in cord compression needs
early surgical decompression.
Anterior decompression is better.
Early surgical intervention for instability prevents deterioration