3. ANATOMY
• THE SPINAL COLUMN IS MADE UP VERTEBRAE, INTREVERTEBRAL DISK
,LIGAMENTS AND MUSCLES
• A TYPICAL VERTEBRA IS MADE UP OF BODY ,PEDICLE ,LAMINA ,SPINOUS
PROCESS ,TRANSVERSE PROCESS ,FACET JOINT AND VERTEBRAL CANAL
• THERE ARE 31 SPINAL NERVES CORRESPONDING TO EACH VERTEBRAE (8
CERVICAL, 12 THORACIC , 5 LUMBAR ,5 SACRAL AND 1 COCCYGEAL )
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4. VERTEBRAL COLUMN
• CURVED SERIES OF VERTEBRAL BONES
,INTERVERTEBRAL DISCS ,LIGAMENTS AND
JOINTS
• CONSISTS OF 33 BONES , 7 CERVICAL ,12
THORACIC ,5 LUMBAR ,5 SACRAL 4
COCCEGEAL
• TOTAL LENGTH IS 70 CM IN MALES AND 60 CM
IN FEMALES 1/4TH OF THE LENGTH IS BY IV
DISC
• 8% CERVICAL 20 % THORACIC ,12 % LUMBAR
8% SACRAL
• FUNCTIONS ; NEUROPROTECTION ,SUPPORT
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7. Introduction
2% to 5% of trauma will ultimately be diagnosed with a SPINE
fracture of which 65-70 % are sub-axial
57% of these injuries are unstable
MVA,Falling,Assault,
Factors to be carefully assessed include neurologic status, degree
and type of injury, ligamentous disruption, spinal stability, and
neural compression.
Adequate decompression of neural elements and restoration of
spinal stability for early mobilization is the basis of treatment.
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8. Classification systems
the “ideal” classification system must have excellent interobserver
and intraobserver reliability, quantify stability, predict prognosis,
and dictate treatment.
The Allen-Ferguson system
based on mechanism of injury
AO; based on morphology
White and Punjabi
Attempts at quantifying biomechanical stability
assesses injuries to the disco-ligamentous complex in addition to
neurologic and bony injuries
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11. Evaluation
ATLS protocol Airway ,breathing ,circulation
Symptoms & signs of spine injury
Midline back tenderness or back pain
limited range of movement ,
decreased mentation ,
neurologic deficit,
urine retention
Neurologic examination :
sensory level
power .
Perianal sensation and anal tone
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15. Specific injuries
Simple Compression Fractures
collapse of a vertebra , wedge shaped ,usually
stable ,only anterior column ,mostly managed
conservatively with cervical orthosis
Burst Compression Fractures
axial loading , middle column , retropulsion of
bone into the spinal canal
indications for surgery
significant vertebral body height loss (> 40%) or
kyphosis >20 degrees,incomplete injury
,significant canal compromise
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17. Simple Posterior Element Fractures
Isolated fractures of the spinous process,
lamina, lateral mass, or pedicle
are stable injuries when occurring in isolation
Spinous process fractures are most
commonly seen at C6 and C7 and is
classically known as the “clay shoveler
fracture” when occurring at C7
External immobilization
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18. General management
Immobilization ;Collar ; Spine Board
Traction ; dislocation
Respiratory support
Blood pressure control : MAP; between 85 and 90 mm Hg is
recommended for 7 days following an acute spinal cord injury
Pharmacologic Therapy
methylprednisolone ???
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19. Management cont…
indication for decompression
radiographic evidence of bone or foreign material in the spinal
canal with cord symptoms
complete block on CT, myelogram, or MRI
clinical judgment
ascertain stability of the injury
unstable fractures; traction. halo., surgical fusion, followed
by orthosis, surgical fusion with internal immobilization
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The interobserver and intraobserver reliability for the total CSISS and total SLIC score are excellent. There is poor interobserver reliability and excellent intraobserver reliability when a total kappa score is calculated using all 21 groups for the Allen-Ferguson system. With respect to surgical management decisions, the interobserver agreement is moderate and the intraobserver agreement is excellent
AIS grading system does not take into account other neurologic findings present in SCI such as spasticity, pain, or dysesthesias all of which contribute to functional recovery and quality of
widely used and highly reproducible, the AIS interpretation of neurologic status often oversimplifies neurologic symptoms. For example, classification of unilateral spinal cord injury or cauda equina remains difficult and often under represents the true severity of injury
Many classification systems have been developed to document and standardize neurologic evaluation of the patient with acute spinal cord injury.14 These include the Frankel Scale,15 the Lucas and Ducker Neurotrauma Motor Index,16 the Sunnybrook,17 the Botsford,18 the Yale scale19 and the National Acute Spinal Cord Injury scales
Currently, the third revision of the SCIM scale, SCIM III, is recommended for functional assessment in patients with acute spinal cord injury.1
These criteria include absence of midline cervical tenderness, absence of focal neurologic deficit, normal alertness, absence of intoxication, and absence of painful, distracting injury.
The modified Memphis criteria are a set of screening criteria for blunt cerebrovascular injury (BCVI) in trauma. The presence of one or more of these criteria makes necessary a complementary CTA or DSA study to exclude a BCVI.
The screening protocol criteria for BCVI are:
base of skull fracture with involvement of the carotid canal
base of skull fracture with involvement of petrous temporal bone
cervical spine fracture
neurological exam findings not explained by neuroimaging
Horner syndrome
Le Fort II or III fracture pattern
neck soft tissue injury (e.g. seatbelt sign, hanging, hematoma
posterior marginal line (PML
anterior marginal line
spinolaminar line
posterior spinous line
retropharyngeal
C1 8.5 10
unreliable
C2–4 6–7a 5–7
retrotracheal C5–7 18 22 14
Canal diameter 15+_ 5
Interspinous distances
These injuries occur in the setting of trauma but are more common in patients with osteoporosis, lytic lesions, or congenital bone disorders such as osteogenesis imperfecta
The middle column is uninvolved and the fracture does not affect the posterior vertebral body wall. The posterior column also remains intact and the posterior ligamentous structures retain their integrity
Burst fractures are high-energy compression fractures that involve the middle column and disrupt the posterior vertebral body wall
Widening between the pedicles is also frequently observed.
immobilization should include a cervical collar, a long or short backboard, and straps to immobilize the patient’s entire body.75 This immobilization before prehospital transport will limit spinal motion and thus injury during transport.76 Immobilization in this way does have complications including pain,77 increased intracranial pressure,78 pressure sores,79 and decreased respiratory function.80 Immobilization should therefore be removed when it is deemed unnecessary.
patients with penetrating injuries to the spine, immobilization should not be performed
It is suggested that, in awake patients, reduction be performed with monitoring to ensure deterioration does not occur.89 Here, it is not recommended to obtain a prereduction MRI, as this may unnecessarily delay reduction of the injury.
For patients in whom a neurologic examination is not possible, a prereduction MRI is recommended
it is recommend based on anatomic and biomechanical perspectives
emergency medical services (EMS) personnel using National X-Radiography Utilization Study (NEXUS)–like criteria.74 These criteria would include midline cervical tenderness, focal neurologic deficit, decreased level of consciousness, intoxication, and other distracting injury.38
immobilization should include a cervical collar, a long or short backboard, and straps to immobilize the patient’s entire body
Immobilization in this way does have complications including pain,77 increased intracranial pressure,78 pressure sores,79 and decreased respiratory function.80 Immobilization should therefore be removed when it is deemed unnecessary. In patients with penetrating injuries to the spine, immobilization should not be performed
