Spinal injuries

1. Spinal Injury

2. Anatomy of Spinal Cord

3. • The spinal cord extends from the foramen magnum where it is continuous with
the medulla olbangata in brainstem and continues through to the conus
medullaris near the second lumbar vertebra, terminating in a fibrous extension
known as the filum terminale.
• The spinal cord is 40 to 50 cm long ( varies between male & female as in male it
is longer ) and 1 cm to 1.5 cm in diameter.
• It made with the brain the Central Nervous System ..
• Function of spinal cord :
1- as a conduit for motor information
2- as a conduit for sensory information
3-coordination of reflexes
• It is divided into five regions:
1-cervical (C) ….. C1-C8
2-thoracic (T) ….T1-12
3-lumbar (L) ……L1-L5
4-Sacral (S) ……S1-S5
5- Coccygeal ( Co )…..Co1

4. • The Spinal Cord is enlarged in the cervical and lumbar
regions :
1- The cervical enlargement : located from C3 to T2 spinal
segments, is where sensory input comes from and motor output
goes to the arms
2- The lumbar enlargement : located between L1 and S3 spinal
segments, handles sensory input and motor output coming from
and going to the legs.

5. • The spinal cord(and brain) are protected by three layers of tissue or
membranes called meninges, that surround the canal :
1- The dura mater is the outermost layer, and it forms a tough protective
coating( Between the dura mater and the surrounding bone of the
vertebrae is a space called the epidural space. )The epidural space is filled
with adipose tissue, and it contains a network of blood vessels.
2-The arachnoid mater is the middle protective layer.
3-Pia mater and the space between the arachnoid and the underlying pia
mater is called the subarachnoid space. The subarachnoid space
contains cerebrospinal fluid (CSF)

6. • Two consecutive rows of nerve roots emerge on each of its
sides. These nerve roots join distally to form 31 pairs
of spinal nerves as they contain motor and sensory nerve
fibers to and from all parts of the body.. The spinal cord is a
cylindrical structure of nervous tissue composed of white
and gray matter.

7. Spinal cord legaments
Intrasegmental
􀁺Ligamentum flavum
􀁺Intertransverse ligament
􀁺Interspinous ligament
Intersegmental
􀁺ALL
􀁺PLL
􀁺Supraspinous ligament

8. SPINAL CORD INJURY
•

9. • SCI :Insult to spine resulting in a change in the normal motor, sensory or
autonomic function.
**This change is either temporary or permanent .
• injury to :
 - vertebral column
 - spinal cord
 - Nerves roots
Epidemiology :
• Incidence 2-5/100,000 .
• Adolescent and young adults are the most commonly affected .
• Most common cause of SC injury : RTA
• Although the majority of spinal injuries do not affect the cord or spinal roots ,
about 10% will result in quadriplegia or paraplegia .

10. • Secondary Injury versus Primary Injury:
A-Primary Injury
–Spinal Injury that occurred at time of trauma
B-Secondary Injury
–Spinal Injury that occurs after the trauma
–possibly secondary to mishandling of unstable
fractures , swelling and Ischemia .

11. Cervical region
• most vulnerable
• C5/6 is the most common site
Thoracic region
• protected by the immobility provided by the ribs
Thoracolumbar junction
• the less mobile thoracic vertebra joins the more mobile lumbar
vertebra making it more susceptible to injury
Lumbosacral region
• the area in which the spinal cords ends and the quada equina
begins
** most commonly vertebrae affected are :C5_C7 & T12 &L1

12. Causes of injury :
1-force
2-Ischemia due to vascular injury
3-Secondary hemorrhage in and around the cord.
** Stability
• Stable : If the ligamentous and bony component of the spine are preserved .
• Unstable: If the ligamentous and bony component of the spine are not preserved .
**Type of neurological impairment
• Complete : no preservation of neurologic function distal to the level of injury
{flaccid paralysis + total loss of sensory & motor functions}
• Incomplete: preservation of any sensorimotor function below the level of injury
constitutes an incomplete injury {mixed loss
- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome }

13. American Spinal Injury Association Impairment Scale (AISA) Classification

14. • Motor level = the last level with at least 3/5
(against gravity) function
• Sensory level = the last level with preserved
sensation
• Dermatome: patch of skin innervated by a
given spinal cord level
• Myotome : Spinal nerve roots which
innervates muscles groups. Most muscles are
innervated by more than one root.

15. Motor Function

16. Sensory Function

18. • Mechanisms and Associated Injuries ( directional force )
1. Hyperextension
– Cervical & Lumbar Spine
– Disk disruption
– Compression of ligaments
2. Hyperflexion
– Cervical & Lumbar Spine
– Stretching of ligaments
– Compression Injury of cord
– Disk disruption with potential vertebrae dislocation
3. Rotational
– Most commonly Cervical Spine but potentially in Lumbar Spine
– Stretching and tearing of ligaments
– Rotational subluxation and dislocation
4. Compression
– Most likely between T12 and L2
– Ruptured disk
5. Distraction
Most common in
upper Cervical Spine
Stretching of cord
without damage to
spinal column.
6. Penetrating
Forces directly to
spinal column
Disruption of ligaments
Direct damage to cord

19. • Cervical Spine Fractures and Dislocations
• classified on the basis of:
• mechanism
– Flexion
– Extension
– Compression
– Rotation
– a combination of these
• Location
• stability

20. Upper cervical spine ( skull to C2 )
1) Craniocervical Dislocation (anterior , posterior or vertical )
including atlanto- axial and atlanto-occipital dislocation
• Cause : high energy trauma
• Usually fatal , but Early diagnosis and spinal stabilization protected
against worsening spinal cord injury
• Careful occipitocervical fusion is required in survivals
• Halo brace should be applied before surgery to prevent intraoperative
dislocation
2) Atlantoaxial instability
The most common is rotatory subluxation in children
• usually spontaneous ( bone or ligament abnormality) but can be
traumatic
• child presents with cock-robin appearance ( head tilt toward the
affected site with contralateral chin rotation )
• halter traction results in realignment in the majority of cases .

22. 3) Jefferson’s fracture ( C1 ring )
Results from fracture through C1 arches
• Associated with axial loading of cervical
spine .
• Can be : stable or unstable
• Transverse ligament rupture may occur
• unstable jefferson’s fracture should be
treated in a halo jacket for 3 months ,followed
by flexion-extension stress radiography

23. 4) Odontoid fracture
• * It results from hyperflexion injury
1. At the tip (type I) - stable
2. Through the base of the dens (type II) (the
most common) - unstable
3. Through C2 vertebral body (type III) -
generally unstable

24. • 5) Hangman’s fracture
• Fracture through the pedicles of C2
• It occurs due to hyperextension
• Usually stable
• Majority can be treated non-operatively: halo jackets or brace
• Those with significant displacement or associated facet
dislocation requires surgery .

25. • 6) Occipital condyle fracture
• Uncommon injury , usually associated with head
injury
• Identified on CT
• Can be treated in hard collar for 8 weeks .

26. • Subaxial cervical spine (C3-C7)
1) Flexion rotation injury :
Most common cervical injury
• Mainly at C5/C6
• Unstable
• Extensive damage to posterior ligaments
• It may sustain both direct damage and
vascular impairment
• It leads to 2 types of fractures:
• A)wedge fractures B)tear drop
fractures

27. A) Wedge fracture :
mostly stable
treatment : brace or halo for 3 months
B) Tear drop fratcure :
• Results in an anteroinferior vertebral body fracture & is more common
in lower cervical vertebrae , C5
• Note : Hyperextension tear drop fracture is more common in upper
cervical vertebrae

28. 2) compression (axial
loading) :
• Mainly at C5/C6
• Vertebral body is decreased in height
• Usually stable (no damage to posterior
Bony structures or longitudinal
ligaments)
Resulting injury:50% complete
50% incomplete (anterior cord
syndrome)
***anterior cord syndrome : involvment of
anterior two thirds of spinal cord which
include the spinothalamic and
corticospinal tracts
• May result in burst fractures : in which
bone fragments may explode into the
cord

30. hyperextension :
- Most common in the elderly patients. With
degenerative spinal canal stenosis
- Usually no bone injury, only damage to ant.
Long. Ligament
- Results in incomplete injury
- Mostly stable
- The most common neurological impairment is
Central Cervical Cord syndrome

31. 4) facet subluxation / dislocation
Either unifacet or bifacet
-Unifacet:
-Result from flexion and rotation
-Posterior ligament is ruptured
-stable, because the vertebra are locked in place
-Bifacet:
-it’s unstable
-high incidence of cord damage

32. Cervical Injury leads to:
• Quadriplegia or quadriparesis
• Bowel/bladder retention (spastic)
• Various degrees of breathing difficulties
• Neurogenic and/or spinal shock
• *quadriplagia: it refers to impairment or loss of motor
and sensory function in the cervical segments it
results in impairment in the function of arms, trunk,
legs and pelvic organs (it does not include the
brachial plexus)
• *quadriparesis:it describes incomplete lesions
imprecisely, the ASIA scale provide a more precise
approach.

33. • Thoracic spine injuries T2-L1:
- Causes paraplegia or paraparesis
- Upper Motor Neuron symptoms
(weakness,decreased motor control,altered
muscle tone,exagerated deep tendon reflexes
spasticity and clonus)
1) flexion, flexion-rotation :
Mostly at level of T12/L1
Unstable
Disruption of post. longitudinal ligament and post.
Bony structures
Anterosuperior wedge fractures are seen
Complete neurological damage (of spinal cord, conus
medullaris, cauda equina)

35. 2) Compression : give an example????  3
Very common
Stable, rarely cause neurological damage
Decrease in height of vertebral body

36. 3) hyperextension :
• Uncommon
• Leads to :
- damage to ant. Longitudinal
ligament
- rupture of intervertebral disc
- fracture of ant. Part of the
involved vertebral body
• Unstable, causes severe neurological
damage
4) Open injury :
• Results from stab or gunshot wounds
• Injury is due to :
- blast injury

37. • 5- Chance fracture is a flexion injury of the
spine,[ It consists of a compression injury to the
anterior portion of the vertebral body and a
transverse fracture through the posterior
elements of the vertebra and the posterior
portion of the vertebral body. It is caused by
violent forward flexion, causing distraction injury
to the posterior elements.
• The most common site at which Chance
fractures occur is the thoracolumbar junction
(T12-L1)

39. • Lumbar spine injuries L1 and below
• Mainly affect cauda equina
• Leads to paraparesis or paraplegia
• Lower Motor Neuron symptoms(flaccid
paralysis, muscle wasting, fibrillation,
fasiculation, hypotonia~atonia,hyporeflexia)

40. • Radiologic investigation:
1) plain X-ray
2) Dynamic X-ray(named dynamic flexion-
extension x-ray)
3) CT (for bone injury, DO NOT give contrast)
4) MRI (for cord, soft tissues and ligament
damage, an emergency only in cauda
equina syndrome)

41. Principles in Treatment

42. 1. To relieve any reversible neural compression.
1. To preserve neurological function.
2. To restore alignment of the spine.
3. To stabilize the spine.
4. To rehabilitate the patient.
-Indications for urgent surgical
stabilization:
1. Unstable fracture with progressive neurological
deficit,
2. An unstable fracture in a pt with multiple injuries.

43. Disc Prolapse

44. - This disc degeneration results from the aging process
and wear and tear that occurs to the bone and soft
tissues of the spine.
- It is one of the most common causes of low back and
neck pain and a major cause of chronic disability in the
adult working population and a common reason for
referral to MRI.

45. >>Degenerative Disc Disease is a Misnomer ! WHY ?
- First , For most people the
term degenerative understandably implies that the
symptoms will get worse with age. However, the term does
not apply to the symptoms, but rather describes the process
of the disc degenerating over time.
- Another source of confusion is probably created by the
term disease, because degenerative disc disease is not
really a disease at all, but rather a degenerative condition
that at times can produce pain from a damaged disc

46. Types of degenerative disc disease
:
1. Cervical Disc Prolapse
2. Degenerative Lumbar Disc
Diseases
3. Spinal Stenosis
4. Spondylolisthesis

47. • Direction of herniation/prolapse :
1. Posterolateral
2. Posterior/Central
3. Lateral

49. Cervical disc prolapse

50. • Prolapse of an intervertebral disc in
the cervical region
• It is less common than disc prolapse
in the lumbar area.
• The disc herniation occurs most frequently at the C6/C7 (70%) level and slightly
less commonly at the C5/6 level (20%) due to the force exerted at these levels .
• Disc herniation above these levels and at the C7/T1 level is much less common

51. Because the nerves pass directly laterally from the
cervical cord to their neural foramen, so that the
herniation compresses the nerve at that level

52. Causes of
cervical disc
prolapse :
Repetitive cervical stress
Trauma
Heavy lifting
Prolonged sedentary position
Whiplash accidents
Frequent acceleration/deceleration

53. Clinical presentation
1. Neck pain
2. Arm pain
3. Hand and fingers pain
4. Part of the shoulder
>> These neurological deficits are determined
by the location of the herniated disc
The pain usually begins in the
cervical region but then it radiates
into the periscapular area, the
occiput, shoulder and down to the
arm.

54. Radiologic Imaging
Investigations
High-quality MRI is now the investigation of
choice and has almost completely replaced
both myelography and CT scans .
Although myelography is an invasive test , it is
more sensitive even to subtle nerve root
compression

57. Management
Conservative(non-surgical) treatment
Patients may find relief by
• using medications to control pain and
inflammation (NSAIDs)
• Use of a cervical collar, cervical pillows
or neck traction may also be
recommended to stabilize the neck and
improve neck alignment.
• exercising the neck and shoulder areas
(alone or with the help of a professional
familiar with neck conditions) to relieve
stiffness and maintain flexibility

58. Lumbar disc prolapse
About 75% of total spinal movement & of lumbar flexion–
extension occurs at the lumbosacral junction ( L5/S1 ),
20% at ( L4/L5 ) level, 5% at upper lumbar levels.
>> Consequently, about 90% of lumbar disc prolapses
occur at the lower two lumbar levels;
The most frequently affected disc is at L5/S1 level

61. Directions of prolapse
Posterolateral (most common)
Lateral
Central (compresses cauda equina)
>> Posterolateral prolapsed disc : causes compression of the nerve
which runs along the posterior aspect of the disc and down in the
neural foramen under the pedicle of the vertebra below
>> Lateral disc prolapse : will cause compression of the nerve root
passing below the pedicle of the vertebra above the disc prolapse.
e.g. :
L3/L4 posterolateral disc prolapse : L4 nerve root compression
Lateral : L3 compression

63. Investigations
• ( 1 ) Lumbar myelography
Involves injection of a water-soluble
contrast material into
the subarachnoid space
that demonstrate the spinal canal.
• Risk of:
• Headache
• epileptic seizures
• In the past the use of oil-based material
was associated with a risk of arachnoiditis

65. ( 2 ) CT scan & MRI

66. Management
• 1.Conservative
• 2. Surgery
Most patients improve by conservative
treatment while Less than 20% require surgery.
• According to the pathology of the disc prolapse:
• A‘bulging’ disc is likely to settle with simple conservative
management,
• If the nucleus pulposus has herniated out of the disc space and
‘sequestrated’ outside the annulus, it will need surgery for
satisfactory relief of symptoms

67. Conservative treatment
1- Bed rest, usually for a period of about 7–10
days
2- Analgesic agents
3- NSAID’s
• Conservative treatment help in:
1.Resorption of the prolapsed disc material
2.Decreasing nerve edema
3.Possible adaptation of the pain fibers to
pressure

68. Indication for surgery
1- Pain if persists after 7-10 days of bed rest OR
reccurent
episodes of pain when mobilizing.
2- Neurological deficit :
A significant weakness or increasing amount of
weakness.
3- Central disc prolapse :
In cases of bilateral sciatica or other features indicating
a central disc prolapse, such as sphincter disturbance
and diminished perineal sensation.
As it cause irreversible cauda equina compression.
4- Tumor

69. scoliosis
• Scoliosis is an (sideways)
of the spine.
• ‘apparent ‘ because although lateral curvature
does occur , the commonest form of scoliosis
is actually a deformity with ,
and
components .
• Two broad types of deformity are defined :
and

71. kyphosis
Rather confusingly , the term ‘kyphosis’ is used to
describe both the (the gentle rounding of the
thoracic spine)and the (excessive thoracic
curvature or straightening out of the cervical or lumber
lordotic curves) .
thoracic curvature might be better describe as
’
, or , is a sharp posterior angulation due to
localized collapse or wedging of one or more vertebrae
This may be the result of a defect , a
(sometimes pathological ) or spinal

75. Myotome
Spinal nerve roots which innervates
muscles groups. Most muscles are
innervated by more than one root

77. THANK YOU..