5. CERVICAL VERTEBRA
C1 (Atlas) C2 (Axis)
•Ring shaped
•2 lateral masses with facets
•2 arches connect lateral masses : ant
& post tubercle
•Transverse process has a foramen
•Lacks a body and a spinous process
• Parts: Body, the dens /odontoid
process
•The articulation formed between the
anterior arch of the atlas and dens
and between their articular facets, is
called the atlanto-axial joint
6. Characteristics Cervical Thoracic Lumbar
Vertebral body Small, oval, curved
faces
Medium, heart
shaped
Largest
Vertebral
foramen
Large Smaller Smallest
Spinous process Long, split tip,
points inferiorly
Long, not split,
project inferiorly
Blunt, broad,
project posteriorly
Transverse
process
Have transverse
foramina
All but 2 have facets
for rib articulations
Short, no articular
facets or transverse
foramina
Articular facet
for ribs
Absent Present Absent
7. Sacrum Coccyx
•Triangular, formed by the union of five
sacral vertebrae (S1–S5)
•Articulates with L5 & coccyx
•Has 2 large L shaped facets (on lateral
surface) for articulation with pelvic bones
• Triangular, formed by the fusion of four
coccygeal vertebrae
• The dorsal surface of the body of the
coccyx : coccygeal cornua that are
connected by ligaments to the sacral cornua
• Lateral surfaces: transverse processes
• Articulates superiorly with the apex of the
sacrum
8. FUNCTION
1. Strong, flexible rod that can move forward, backward, sideways,
and rotate - Allow movement
2. Supports the body weight
3. Serves as a point of attachment for the ribs, pelvic girdle, and
muscles of the back and upper limbs.
4. To enclose and protect the spinal cord & nerve roots.
9. CLINICAL PRESENTATION
Lumbar Vertebral Fracture
• Moderate to severe back pain, worsening by movement.
• Spinal cord involvement :
- bowel/bladder dysfunction
- Numbness/ tingling sensation
- Weakness in the limbs
• High energy trauma : brain injury, loss of consciousness.
11. Emergency Management
1. Initial assessment and stabilization
ABC algorithm
Rapid assessment and treat life treatening injuries
2. Secondary survey
Look for other associated injuries (brain injury, thoracic injury, abdominal injury).
Might do neurological examination to determine any presence of neurological
deficit.
3. Immobilization
To avoid injuries during transport and prehospital phase.
12. METHODS OF TEMPORARY IMMOBILIZATION
• Cervical spine – use in line immobilization, head & neck supported in neutral
position.
• Quadruple immobilization
- applied backboard, sandbags, forehead tape, semi-rigid collar.
• Thoracolumbar spine
- scoop stretcher & spinal board
- log rolling technique
14. DENNIS THREE COLUMN
1. To assess the spinal stability
2. Particularly useful in assessing the stability of lumbar injuries
3. 3 structural elements must be considered
• posterior column
• middle column
• anterior column
15.
16. STABLE INJURY UNSTABLE INJURY
• The vertebral components will
not be displaced by normal
movements
• Significant risk of displacement
and consequent damage
• Little risk of neural elements
becoming damaged
• May cause further damage to
the neural tissues
22. • Posterior ligaments remain intact
• Fracture usually stable
• Neurological injury is rare
23.
24. Treatment
Minimal wedging & a stable
fracture
Bed rest (1/ 2 weeks) until pain subsides
Then mobilized; no support is needed.
Moderate wedging (loss of 20–
40 % of anterior vertebral
height) & a stable injury
Wearing a thoracolumbar brace or a body cast
applied with the back in extension. (can be
allowed up after a week)
Loss of anterior vertebral height
is greater than 40 %
surgical correction & internal fixation is the
preferred treatment.
Wedge compression fracture and
neurological impairment
Operative decompression & stabilization through
a trans-thoracic approach.
Complete paraplegia with no
improvement after 48 hours
Conservative management is
• Bed rest for 5–6 weeks
• gradually mobilized in a brace.
Increasing kyphosis - internal fixation
25. Burst injury
• Severe axial compression
• Lead to damage of both the
anterior and the middle columns.
• The posterior column undamaged.
• Bone fragments and disc may be
displaced into the spinal canal
• Unstable fracture
31. Flexion-distraction
• Jack-knife injury
• Common in lap seat-belt injuries
• Anterior column fails under compression
• Posterior and middle column fail under tension
32. • Usually patient is neurologically intact
• Associated with intra abdominal injury
• Unstable fracture
33. Lateral view: widening of L1 disk
space, perching of facet L1 on L2
AP view: apparent height of the
vertebral body may be increase
34.
35. Treatment
• Bony fracture: 3 months body cast or well-fitting brace
• Ligamentous injury : Posterior spinal fusion
36. Fracture-dislocation
• Segmental displacement occur with various combinations of flexion,
compression, rotation and shear.
• 3 columns involved
• Unstable injury
• Often associated with neurological damage to the lowermost part of
the cord / cauda equina
• Common- thoracolumbar junction
37. • X-rays : fractures through the vertebral body, pedicles, articular
processes and laminae; there may be varying degrees of subluxation
or even bilateral facet dislocation
• CT scan : shows a degree of spinal canal occlusion
39. Treatment
Fracture-dislocation with paraplegia - Non-operatively by postural
reduction, bed rest and bracing
Fracture-dislocation with partial
neurological deficit
- Surgical decompression and
stabilization (no evidence operative
management > conservative)
Fracture-dislocation without
neurological deficit
- Surgical stabilization
- Rehabilitation
41. SPINAL CORD INJURY
An insult to the spinal cord resulting in a change, either temporary
or permanent, in its normal motor, sensory or autonomic function
BAIHAQI
47. complete Incomplete
•an injury with no spared motor or
sensory function below the affected
level.
•patients must have recovered from
spinal shock (bulbocavernosus reflex
is intact) before an injury can be
determined as complete
•classified as an ASIA A
•an injury with some preserved motor
or sensory function below the injury
level
•incomplete spinal cord injuries
include
• anterior cord syndrome
• Brown-Sequard syndrome
• central cord syndrome
• posterior cord syndrome
• conus medullaris syndromes
• cauda equina syndrome
48. Consequences
1. Motor disturbance
- paralysis, atrophy
2. Sensory disturbance
- loss, diminished,
hyperesthesia,
- pain
3. Change of reflex/tone
hypo-, hyperreflexia,
spasticity
4. Autonomic disturbances
- bladder & bowel
dysfunction
- loss of thermoregulation
- erectile dysfunction
49. Central Cord
Syndrome
most common & good
prognosis
MECHANISM OF INJURY
• Cervical hyperextension
injury → spinal cord
compression and central
cord edema
SYMPTOMS
• Bilateral motor weakness
(upper > lower)
• Hyperpathia (burning
sensation)
• bladder symptoms (urinary
retention) may also occur.
50. Anterior Cord
Syndrome
worst prognosis of
all incomplete cord injury
(mimic complete sci)
MECHANISM OF INJURY
• Flexion/Compression injury
→ direct
compression/anterior spinal
artery injury
SYMPTOMS
• Motor paralysis
• Loss of pain & temperature
sensation
• Preserved proprioception,
touch & vibration sensation
53. Cauda Equina Syndrome
SYMPTOMS
• back pain, leg pain
(bilaterally or unilateral)
• saddle anesthesia
• impotence
• sensorimotor loss in lower
extremity
• neurogenic bladder
dysfunction – urinary
retention, overflow
incontinence
• bowel dysfunction is rare
a constellation of symptoms that result from terminal spinal nerve
root compression in the lumbosacral region(roots- l1 to l5, s1 to
s5)(vertebrae below l2)
55. SPINAL SHOCK
Transient physiologic reflex depression of cord function below the
level of injury
MECHANISM: neurons become hyperpolarized and unresponsive to
stimuli from brain
SYMPTOMS
• Flaccid muscle
• Absent reflex
• Loss of sensation
• Bradycardia & hypotension (due to loss of sympathetic tone)
DURATION: Rarely lasts for more than 48 hours
ASSESSMENT: Return of the bulbocavernosus reflex (BCR) marks
the end of ‘spinal shock’
56. • These changes consist of three main phases:
1. Reduction of reflex activity results from decreased excitability of spinal
motor neurons
2. Resumption of reflex activity or voluntary movement is attributed to
denervation hypersensitivity
3. Hyperreflexia occurs due to new synaptic growth.
4. Consequently, the motor neuron below the level of injury is predominantly
under either voluntary or reflex control.
5. As a result, various levels of spasticity develop or, in case of an
incomplete lesion, voluntary movement might be recovered, depending on
the extent of spinal cord injury.
57.
58. NEUROGENIC SHOCK
Characterized by hypotension & relative bradycardia in patient with an
acute spinal cord injury & potentially fatal
MECHANISM:
• circulatory collapse from loss of sympathetic tone
RESULT:
disruption of autonomic pathway within the spinal cord leads to
• lack of sympathetic tone Bradycardia
• decreased systemic vascular resistance vasodilation pooling of
blood in extremities dry & warm extremities
• Hypotension decreased blood Pa
59. Spinal Shock Neurogenic Shock
BP Hypotension Hypotension
Pulse Bradycardia Bradycardia
Reflexes / Bulbocavernosus
Reflex
Absent
Variable/independent
Motor Flaccid Paralysis
Variable/independent
Time
~48-72 hours immediately after spinal cord injury
~48-72 hours immediately after spinal cord injury
Mechanism
Peripheral neurons become temporarily unresponsive to
brain stimuli. Disruption of autonomic pathway leads to loss of
sympathetic tone and decreased systemic
vascular resistance.
61. ASIA CHART
• To define and describe the extent and severity of patient’s spinal cord
injury.
• To document sensory and motor impairment following spinal cord
injury.
• Help determine future rehabilitation and recovery need.
62.
63. 1. Determine sensory levels for right and left
sides.
• Use the score 0, 1 and 2 for each dermatome. Labeled
as NT(not testable) if cannot be tested.
• Score as below:
• 0: no sensation
• 1: sensation present but impaired
• 2: normal sensation
• Pin prick and light touch sensation.
• The sensory level is the last level that have normal
sensation for both pin prick and light touch
sensation.
64.
65.
66. 2. Determine motor levels for right and left
sides.
• The motor level is the lowest key muscle function that has a grade of
at least 3 (on supine testing), providing the key muscle functions
represented by segments above that level are judged to be intact
(graded as a 5).
• In regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor
function above that level is also normal.
67. • 0 Total paralysis
• 1 – Palpable or visible contraction
• 2 – Active movement, full range of motion, gravity
eliminated
• 3 – Active movement, full range of motion, against
gravity
• 4 – Active movement, full range of motion, against
gravity and provides some resistance
• 5 – Active movement, full range of motion, against
gravity and provides normal resistance
• NT – not testable.
68.
69. 3. Determine the neurological level of injury
(NLI).
• The most caudal segment of the cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there
is normal (intact) sensory and motor function rostrally respectively.
70.
71. 4. Determine whether the injury is complete
or incomplete.
• Complete (absence sacral sparing).
• If voluntary anal contraction = No
• AND all S4-5 sensory scores = 0
• AND deep anal pressure = No,
• Incomplete (presence sacral sparing).
73. 5. Determine ASIA impairment scale (AIS)
grade.
Is injury
complete?
AIS=A
Is injury
motor
complete
AIS=B
Are at least half
of the key
muscles below
the
neurological
level of injury
graded 3 or
better?
AIS=C
AIS=D
If sensation and motor function is
normal in all segments, AIS=E.
YES
YES
YES
NO
NO NO
74. • A = Complete.
• B = Sensory sparing only.
• Sensory but not motor is preserved below the neurological
level and includes the sacral segment S4-5.
• C = Motor Incomplete.
• Less than half of key muscle functions below the single NLI
have a muscle grade ≥ 3.
• D = Motor Incomplete.
• At least half of key muscle functions below the single NLI
having a muscle grade ≥ 3.
• E = Normal.
82. As the segments of the spinal cord are left above the
respective vertebra, when a particular vertebra is
injured, it will give rise to injury of segment of the spinal
cord near to it, which is lower than the numerically
corresponding segment.*****
Clinically, it is important to know the segment of spinal cord
likely to be affected in vertebral injury.
Rough guide to estimate it *****:
Vertebra: Add : Spinal Segment
Lower cervical: C5 : +1 : C6
Upper thorax: T4 : +2 : T6
Lower thorax: T9 : +3 : T12.
To estimate a vertebra and segment of the
spinal cord related*****
83. Cauda equina
Cauda equina occupies the vertebral
canal below the level of the conus
medularis of the spinal cord.
It is made up of:***
• filum terminale,
• roots of spinal nerves
from both sides of:
L2 to L5,
S1 to S5 and
Cox 1 .
84. AETIOLOGY
• Narrowing of the spinal canal can be due to a developmental abnormality or
degenerative process
• spinal disorders such as ankylosing spondylitis, spondylosis, and
spondylolisthesis
Spinal stenosis
• fracture or subluxation
• Penetrating trauma
Spinal trauma
• - 90% at L4-L5 or L5-S1.
• MOST COMMON CAUSE OF CES
Herniated disc
85. • primary or metastatic spinal neoplasms
• ependymoma, schwannoma, and paraganglioma.
• Lung, breast, renal, colorectal, lymphtic
Neoplasm
• Paget disease and ankylosing spondylitis
• epidural abscess
• Pyogenic and non pyogenic
Inflammation
and infection
• spinal instrumentation (misplaced pedicle screws and laminar
hooks)
• Continuous spinal anesthesia
Iatrogenic
causes
86. CONUS MEDULLARIS
SYNDROME (CMS)
• Caused by an injury or insult to
the conus medullaris and lumbar
and sacral nerve roots
• Injuries at the level of T12-L2 and
(S1-S5)
• PATHOLOGY
- conus medullaris is part of spinal
cord lies in close proximity to
nerve roots combined UMNL &
LMNL
CLINICAL PRESENTATION
• saddle anaesthesia (S3-S5)
• loss of bladder reflex: urinary
retention
• loss of bowel reflex: incontinence
• lower limb motor weakness,
paraesthesia and numbness
• Bilateral leg pain
87. PHYSICAL EXAMINATION
• Inspection → lower extremity muscle atrophy
• Palpation → palpation of the bladder for urinary retention
• Neurovascular → bilateral lower extremity weakness, sensory
disturbances, decreased/absent lower extremity reflexes
• Rectal / genital → ↓rectal tone voluntary contracture
• Reflexes of anal and bulbocavernous absent
88.
89. CAUDA EQUINA SYNDROME (CES)
• defined by a constellation of
symptoms that result from
terminal spinal nerve root
compression in the lumbosacral
region
• few true medical emergencies in
orthopaedics
• compression cause LMNL
90.
91.
92.
93.
94. Investigation
Lab -> FBC, ESR
Plain XRay
MRI -> accurate, specific, to
investigate underlying causes,
urgent in pt with urinary
symptoms or sciatica
LP -> CSF
CT and myelograph -> good
accuracy
95. METHOD OF DECOMPRESSION
• surgical decompression as soon as possible becomes mandatory
GOALS
• To relieve the pressure on the nerves
• Increase space of the spinal canal
• Preserve neurological function
• Restore alignment of spine
• Rehabilitate patient
97. SURGICAL METHODS
• CES has been considered a
surgical emergency, with surgical
decompression considered
necessary within 48 hours after
the onset of symptoms
Indications
• significant suspicion for CES
• severity of symptoms will
increase the urgency of surgical
decompression
Techniques
• Discectomy- surgical removal of
herniated disc material that
presses on a nerve root or the
spinal cord.
• Laminectomy- surgery that
creates space by removing the
lamina - the back part of the
vertebra that covers the spinal
canal.
Editor's Notes
Anterior: ant half of vetebral body, ant half of intervetebral disc and anterior longitudinal ligament
Middle: post half of vetebral body, post half of intervetebral disc, post longitudinal ligament
Posterior: pedicles, facet joints, posterior bony arch, interspinous and supraspinous ligament
All # involving middle columnand at least one other column regarded as unstable/2 or more column
Osteoporosis – minor trauma > lift heavyweight, sneezing, fall from standing height
Trauma – car accident, fall off a trampoline paired with forward bend
2-At 3 months, flexion–extension x-rays are obtained with the patient out of the orthosis; if there is no instability, the brace is gradually discarded. If the deformity increases and neurological signs appear, orif the patient cannot tolerate the orthosis, surgical stabilization is indicated.
4- - treatment will depend on the degree of dysfunction and the risk of progression. If nerve loss is incomplete there is the potential for further recovery; any increase in kyphotic deformity or MRI signs of impending cord neurological compression would be an indication for
Fall from height
Neurological injury – it may be resolve overtime, bcos the fragment will be resorb.
AP: interpedicular distance widened, vertebral body height loss
Lateral: kyphotic deformity, retropulsion of fragment into spinal canal
Loss of L1 vertebral body height, particularly anteriorly, focal kyphosis, retropulsion of the posterior vertebral body margin and widening of the pedicle spacing on the AP image consistent with a burst type fracture.
Lateral view = retropulsion of bone into the canal. However it is difficult to see on the plain lateral radiograph; a CT is essential
Type A: Fracture of both endplates (24%)
Type B: Fracture of the superior endplate (49%)
Type C: Fracture of inferior endplate (7%)
Type D: Burst rotation (15%)
Type E: Burst lateral flexion (5%)
Lap seat belt injury- body is thrown forward against a restraining strap.
The tear passes transversely through the bones or the ligament structures, or both
High energy trauma : mva, falls, sports & violence
In neurologically intact patients, most fracture-dislocations will benefit from early surgery.
Complication- Neurological injury- Cauda equina syndrome, DVT, Non-union after spinal fusion, Post-traumatic pain, most common complication greater with increased kyphotic deformity
Deformity –Scoliosis, progressive kyphosis common with unrecognized injury to PLL flat back leads to pain, a forward flexed posture, and easy fatigue post-traumatic syringomyelia
Mechanism of Injury
Destruction of cord parenchyma
From direct trauma
Compression by bone fragments, haematoma or disc material
Ischaemia from damage or impingement on spinal arteries
Inflammation
Spondylotic myelopathy
spondylosis, spondylolisthesis
Disc herniation, rupture
Infectious and inflammatory diseases
MS
Epidural abscess
Transverse myelitis
Osteomyelitis
Arachnoiditis
HIV
CIDP, AIDP
Neoplastic diseases
Malignant, metastatic tumor
Nonmalignant tumor
Vascular disorders
Ischemic myelopathy
Congenital and development disorders
Spina bifida, Myelodysplasia
Developmental syringomyelia
Toxic and metabolic condition
Radiation-induced myelopathy
Subacute combined degeneration of SC
tetraplegia
injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs
paraplegia
injury to the thoracic, lumbar or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved
thoracolambar
Symp t1 to l2
Para s2-s4
Cranosacral
Symp c3,7,9,10
Often in elderly with minor extension injury mechanisms due to anterior osteophytes and posterior infolded ligamentum flavum
Due to the anatomical lamination of the corticospinal tract with the arm fibers medially and the leg fibers laterally, the arms are affected more so than the legs, resulting in a disproportionate motor impairment
anatomy of spinal cord explains why upper extremities and hand preferentially affected (hands and upper extremities are located "centrally" in corticospinal tract)
Not fully recovery - rare
recovery occurs in typical pattern:
lower extremity recovers first
bowel and bladder function next
proximal upper extremity next
hand function last to recover
Dorsal column - proprioception & vibratory sense
Contralaterally – pain & tempt 2 level below the lesion
99% ambulatory at final follow up
best prognosis for function motor activity
Motor, pain and light touch preserved.
space-occupying lesion within lumbosacral canal, including
disc herniation (most common) – 1 to 6% lumbar disc hernia
spinal stenosis
tumors
trauma (retropulsion of fracture fragment, dislocation or collapse)
spinal epidural hematoma
epidural abscess
disruption of bladder contraction and sensation leads to urinary retention and eventually to overflow incontinence
S5-S3 nerve give sensory innervation to rectum, perineum and inner thigh
Timing - variable but usually resolves within 48 hours & at its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks
reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter
NT – not testable. Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort or contracture.
A = Complete. No sensory or motor function is preserved in the sacral segments S4-5.
B = Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.
C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body.
(This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.
D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.
E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.
filum terminale
non-neural, fibrous extension of the conus medullaris that attaches to the coccyx
CAuda equina (horse's tail)
collection of L1-S5 peripheral nerves within the lumbar canal
84
85
Spinal stenosis presents with leg discomfort on
walking that is relieved by rest
retropulsion of fracture fragment, dislocation or collapse
epidural abscess, can lead to deformity of the nerve roots and spinal cord
severe back pain and a rapidly progressing motor weakness.
Pyogenic abscesses are generally found in an immunocompromised or poorly nourished host. Staphylococcus aureus causes epidural abscesses. Pseudomonas species, and Escherichia coli
Nonpyogenic causes for abscess are rare and include tuberculosis. uncommon organisms, such as Nocardia asteroides and Streptococcus milleri,
Paget’s disease, in which
enlargement of the vertebrae may encroach on the
spinal canal
Back pain, unilateral/bilateral leg pain
Sexual dysfx- Impotence (inability in a man to achieve an erection or orgasm)
sensory motor loss in lower extremity
Bladder- neurogenic bladder dysfunction
disruption of bladder contraction and sensation leads to urinary retention and eventually to overflow incontinence
receives innervation from
Bowel dysfx is rare
parasympathetic nervous system (pelvic splanchnic nerves and the inferior hypogastric plexus) and
sympathetic plexus (hypogastric plexus)
external sphincter of the bladder is controlled by the pudendal nerve
lower motor neuron lesions of cauda equina will interrupt the nerves forming the bladder reflex arcs
Urinary manifestations of cauda equina syndrome include the following:
Retention
Difficulty initiating micturition
Decreased urethral sensation
Typically, urinary manifestations begin with urinary retention and are later followed by an overflow urinary incontinence
Bowel disturbances may include the following:
Incontinence
Constipation
Loss of anal tone and sensation
Plain x-rays will show structural
abnormalities of the spine;
cord compression
can be visualized by myelography, alone or combined
with CT.
Intrinsic lesions of the cord require further
investigation by blood tests, CSF examination and
MRI.
MRI
study of choice to evaluate neurologic compression
CT myelography
study of choice if patient unable to undergo MRI
pressure on the nerves of the cauda equina by removing the compressing agent
(steroid) Anti-inflammatory medication may prevent worsening of injury.
(prednisolone)This agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. This prevents further worsening of injury.
Anticoagulants (heparin) provide prophylaxis against thrombotic complications.
Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse clot but is able to inhibit further thrombogenesis.
antispasticity medications to reduce muscle tone
preferably performed within 6 h of injury.
The procedure involving removing central portion of intervertebral disc, nucleus pulposus, which cause pain by stressing the spinal cord
