prepared by Dr Sanjib Kumar Das, MPT (Musculoskeletal), Fellow;PhD (Ergonomics and Human Factors)

1. Spinal Injuries
Dr Sanjib Kumar Das, MPT, Fellow(PhD)

2. INTRODUCTION
• Fractures and dislocations of the spine are serious injuries because they
may be associated with damage to the spinal cord or cauda equina.
• About 20 per cent of all spinal injuries result in a neurological deficit in
the form of paraplegia in thoraco-lumbar spine injuries or quadriplegia in
cervical spine injuries.
• Injury to the cervical spine, may lead to paralysis of all four limbs
(quadriplegia).
• In thoracic and thoraco-lumbar spine, it may result in paralysis of the
trunk and both lower limbs (paraplegia).
• Often, the patient does not recover from the deficit, resulting in
prolonged invalidism or death.

3. TRAUMATIC INJURY
• The terms quadriparesis and paraparesis are
sometimes used for incomplete paralysis of all four
limbs or the lower limbs respectively.
PATHOLOGY
The displaced vertebra may either
damage the cord (b), the cord along
with the nerve roots lying by its
side (c) or the roots alone (a).

4. MODE OF INJURY
• A fall from height, e.g., a fall from a tree, is the commonest
mode of sustaining a spinal injury in developing countries.
• In developed countries, road traffic accidents account for the
maximum number.
• Other modes are: fall of a heavy object on the back. e.g., fall of
a rock onto the back of a miner, sports injuries etc.
STABLE AND UNSTABLE INJURIES
• A stable injury is one where further displacement between
two vertebral bodies does not occur because of the intact
‘mechanical linkages’.
• An unstable injury is one where further displacement can
occur because of serious disruption of the structures
responsible for stability.

5. STABLE AND UNSTABLE
INJURIES
• Recent biomechanic studies show: the spine can be divided
into three columns: anterior, middle and posterior.
• When only one column is disrupted (e.g., a wedge
compression fracture of the vertebra) the spine is stable.
• When two columns are disrupted (e.g., a burst fracture of the
body of the vertebra) the spine is considered unstable.
• When all the three columns are disrupted, the spine is always
unstable (e.g., dislocation of one vertebra over other).

6. CLASSIFICATION
Spinal injuries are best classified on the basis of mechanism of
injury into the following types:
• Flexion injury
• Flexion-rotation injury
• Vertical compression injury
• Extension injury
• Flexion-distraction injury
• Direct injury
• Indirect injury due to violent muscle contraction

7. FLEXION INJURY
• This is the commonest spinal injury.
• In the cervical spine, a flexion force can result in:
(i) a sprain of the ligaments and strain of muscles of the back of
the neck
(ii) compression fracture of the vertebral body, C5 to C7
(iii) In the dorso-lumbar spine, this force can result in the wedge
compression of a vertebra (L1 commonest, followed by L2 and
D12).
• It is a stable injury if compression of the vertebra is less than
50 % of its posterior height.

8. FLEXION-ROTATION INJURY
• This is the worst type of spinal injury because it leaves a highly
unstable spine, and is associated with a high incidence of
neurological damage.
• In the cervical spine this force can result in:
(i) dislocation of the facet joints on one or both sides
(ii) fracture-dislocation of the spine.
Here one vertebra is twisted off in front of the one below it. While
dislocating, the upper vertebra takes a slice of the body of the lower
vertebra with it. There is extensive damage to the neural arch and
posterior ligament complex. It is a highly unstable injury.

9. VERTICAL COMPRESSION INJURY
• It is a common spinal injury. Examples: (i) a blow on the top of
the head by some object falling on the head; (ii) a fall from height
in erect position
• In the cervical spine, this force results in a burst fracture i.e., the
vertebral body is crushed throughout its vertical dimensions. A
piece of bone or disc may get displaced into the spinal canal,
causing pressure on the cord. In the dorso-lumbar spine, this
force results in a fracture similar to that in the cervical spine,
occurs with or without neurological deficit due to a wide canal at
this level.
• It is an unstable injury.

10. EXTENSION INJURY
• This injury is commonly seen in the cervical spine. Examples:
(i) motor vehicle accident – the forehead striking against the
windscreen forcing the neck into hyperextension; (ii) shallow
water diving –the head hitting the ground, extending the neck.
• Results: This injury results in a chip fracture of the anterior
rim of a vertebra. Sometimes, these injuries may be unstable.

11. FLEXION-DISTRACTION
INJURY
• With the sudden stopping of a car, the upper part of the body is
forced forward by inertia, while the lower part is tied to the seat
by the seat belt. The flexion force thus generated has a
component of ‘distraction’ with it.
• It commonly results in a horizontal fracture extending into the
posterior elements and involving a part of the body. It is also
termed a ‘Chance fracture’.
• It is an unstable injury.

12. DIRECT INJURY
• This is a rare type of spinal injury.
• Examples: (i) bullet injury; (ii) a lathi blow hitting the
spinous processes of the cervical vertebrae.
• Any part of the vertebra may be smashed by a bullet, but, a
lathi blow generally causes a fracture of the spinous
processes only.
VIOLENT MUSCLE CONTRACTION
• This is a rare injury.
• Example: Sudden violent contraction of the psoas.
• Results: It results in fractures of the transverse processes of
multiple lumbar vertebrae. It may be associated with a retro-
peritoneal haematoma.

13. CLINICAL FEATURES
• A patient with a spinal injury may present in
the following ways:
Pain in the back
Neurological deficit

14. EXAMINATION
Examination consists of the following:
• General examination: A quick examination to be carried out to evaluate any
hypovolaemic shock and associated injuries to the head, chest or abdomen.
• Neurological examination: It is carried out before examining the spine per se.
By doing so, it will be possible to find the expected segment of vertebral
damage. The level of motor paralysis, loss of sensation and the absence of
reflexes are a guide to the neurological level of injury. It is easy to calculate
the expected vertebral level from the neurological level .
• Examination of the spine: Utmost care to be observed during examination of
the spinal column. If such care is not observed, in an unstable spine,
movement at the fracture site may cause damage to the spinal cord. The
patient should be tilted just enough to permit the hand to be introduced under
the injured segment to feel the prominence of one or more of the spinous
processes, tenderness, crepitus or haematoma at the site of injury.

15. INVESTIGATIONS
• Good antero-posterior and lateral X-rays centering on the
involved segment provide reasonable information about the
injury. Sometimes, special imaging techniques are required
e.g., CT scan, MRI etc.
TREATMENT
The treatment of spinal injuries can be divided into three phases,
as in other injuries:
Phase I: Emergency care at the scene of accident or in emergency
department.
Phase II: Definitive care in emergency department, or in the ward.
Phase III: Rehabilitation.

16. PHASE I - EMERGENCY CARE
At the site of accident:
• While moving a person with a suspected spine injury, one person
should hold the neck in traction by keeping the head pulled.
• The rest of the body is supported at the shoulder, pelvis and legs by
three other people.
• Whenever required, the whole body is to be moved in one piece so
that no movement occurs at the spine.
In the emergency department:
• In cases with cervical spine injury, two sand bags should be used on
either side of the neck in order to avoid any movement of the neck.
• A quick general examination of the patient need to be carried out.

17. PHASE II - DEFINITIVE CARE
• The aim of treatment is:
(i) to avoid any deterioration of the neurological status.
(ii) to achieve stability of the spine by conservative or operative
methods.
(iii) to rehabilitate the paralyzed patient to the best possible
extent.

18. WARD CARE OF A PARAPLEGIC
Ward care of a traumatic paraplegic or quadriplegic consists of:
(i)Management of the fracture
(ii)Nursing care
(iii)Care of the bladder and bowel
(iv)Physical therapy

19. MANAGEMENT OF THE FRACTURE
• Conservative treatment of the fracture or fracture-dislocation is the
same as that for spinal injury without neurological lesion.
• Role of operative treatment consists of stabilization of the spine by
internally fixing it. This ensures better nursing care of the patient but
offers no security about the recovery of neurological function. The
generally accepted indications for surgery as follows:
a) Incomplete paralysis, particularly if it is increasing, and a CT scan
shows fragments of bone encroaching upon the spinal canal.
b) Patient with multiple injuries, in whom it is desirable to stabilize
the spine for overall optimum care of the patient.

20. NURSING CARE
a) Positioning in bed: The patient is nursed flat on a hard bed with a
mattress. The limbs are positioned with pillows so that contractures do not
develop; also pressure points are adequately padded .
b) Care of the back: Frequent turning in bed is vital so that the patient lies
for equal periods on his back and on either side. The bed is kept dry and
free of wrinkles. Special beds are available which provide an ease of
turning the patient periodically, and constantly changing pressure-point
(water-bed).
c) Personal hygiene: All personal hygiene of the patient from top to toe, is
to be looked after. This includes combing hair, cleaning teeth, mouth wash,
care of the skin and nails etc.

21. 1. Pillow to support the feet
2. Pillows to keep the knees flexed & separated
from each other
3. Pillow to support the spine
4. Pillow under the head
5. Hard bed

22. CARE OF THE BLADDER
• Intermittent catheterisation is the best but for convenience an indwelling
catheter is used. Catheter is changed once a week, and the patient is kept
on prophylactic antiseptic drugs.
• A urine culture is done once every two weeks. As the patient becomes
haemodynamically stable, catheter is periodically clamped so that the
bladder capacity is maintained.
• In most cases of cord transection, satisfactory automatic emptying is
established within one to three months of the injury (automatic bladder).
• In a case, where the sacral segments are irrecoverably damaged, as in a
cauda equina lesion, reflex emptying does not occur. In such cases,
micturition will have to be started or aided by other mechanisms like
abdominal straining or manual compression etc. (autonomous bladder).

23. CARE OF THE BOWEL
• The patient develops bowel incontinence and
constipation. The latter may result in periodic
bloating up of the abdomen.
• A frequent soap water enema or manual evacuation of
the bowel may be required.

24. PHYSIOTHERAPY
• Aim of physiotherapy in the initial few weeks is to
maintain mobility of the paralyzed limbs by moving
all the joints through the full range gently, several
times a day.
• Later, in cases where partial recovery occurs,
exercises specifically for building up the muscle
groups are taught.

25. PHASE III - REHABILITATION
• In most cases with traumatic paraplegia and quadriplegia, the
deficit is permanent.
• With concentrated efforts at rehabilitation, a majority of these
cases can be made reasonably independent and enabled to lead
a useful life within the constraints of their disability.
Rehabilitation can be considered under the following headings:
(i) Physical rehabilitation
(ii) Psychological and social rehabilitation
(iii) Economic rehabilitation.

26. THANK YOU
Dr. Sanjib Kumar Das, Fellow (PhD) NITIE,
Ergonomics and Human Factors,
Asst. Prof., School of Physiotherapy,
P.P. Savani University, Surat, India
Mail: sanjib_bpt@yahoo.co.in
Contact No. :+91 8879485847