spine

1. SPINE INJURIES
By : halim manam

2. Overview
 Epidemiology
 Anatomy of the spine
 Stable and unstable injuries
 Mechanism of injury
 Cervical Spine Injuries
 Thoracolumbar Injuries

3. Epidemiology
Injuries to the spine structure
3.4:1 Male-to-female ratio
70% of spinal injuries are due to indirect injury
mechanisms (mostly from MVA)
*Article source: What is Spinal Injury? (2009), Dr
Albert Wong, Neurosurgical Association of
Malaysia

4. Anatomy
 33 bony vertebrae: 7 cervical, 12 thoracic,
5 lumbar, 5 sacral (fused), and 4 coccygeal
(usually fused).
 Separated by intervertebral discs and
connected by a network of ligaments.
 Provides the body's basic structural
support and also protects the spinal cord
[midbrain to L2 and then continues as the
cauda equina].

5.  Each vertebra consists of an anterior body and a
posterior neural arch.
 Central part of cancellous bone and a peripheral
cortex of compact bone.
 Neural arch is constituted by pedicles, laminae,
spinous process and articulating facets.
Source: Maheswari, 7th Ed

6.  Atypical cervical vertebrae
- C1 and C2
 Typical cervical vertebrae
- C3 to C7
Source:
Radiopedia.org

8. Stable or unstable?
 Stable injury = vertebral components will not be
displaced by normal movements.
 An unstable injury = significant risk of
displacement and consequent damage to the
neural tissues.
 3 structural elements must be considered in
assessing stability:
Posterior osseoligamentous complex (or
posterior column).
Middle column
Anterior column
All # involving the middle
column and at least one other
column should be regarded as
unstable. –(Denis, 1983)

9. Denis classification 1. Anterior column:
Anterior half of the vertebral body, the
anterior part of the intervertebral discs
the anterior longitudinal ligament.
2. Middle column:
Posterior half of the vertebral body, the
posterior part of the intervertebral discs
and the posterior longitudinal ligament.
3.Posterior column:
Pedicles, facet joints, posterior bony arch,
interspinous and supraspinous ligaments.

10. Mechanism of Injury
 Traction (avulsion) injury – Due to resisted muscle
effort
 Direct injury – Penetrating injuries, firearms or knives
 Indirect injury – Most common, variety of forces
applied to the spine
(axial compression, flexion)

11. E.g. of Indirect injury
Flexion injury
Flexion-rotation injury
Vertical compression
injury
Hyperextension injury
Flexion-distraction
injury
Source: Maheswari, 7th Ed

12. CERVICAL SPINE INJURIES

16. RADIOLOGICAL ANATOMY – OPEN
MOUTH VIEW

17. Types of Cervical Spine
Injuries
Upper Cervical Spine
injuries
Jefferson
fracture
Hangman
Fracture
C2 odontoid
process
fracture
Lower Cervical Spine injuries
burst and
compression-flexion
fractures
Wedge Compression
Fracture
Cervical Facet
Dislocations
& Fractures

18. Upper Cervical Spine injuries
1. C1 ring fracture : Jefferson fracture
• Definition – Bursting apart of lateral masses of C1.
• ‘Bursting’ force – Sudden severe load on top of head
• Usually no neurological damage
• Dx: X-ray on open-mouth view / CT scan
• Tx:
Undisplaced – Cervical collar/ halo vest
If sideways spreading > 7 mm, halo vest for several (6-12) weeks
Op: Only for persisting instability on x-ray.

19. Cervical x-ray: Open mouth view CT scan- cervical spine – Axial view

20. 2.Hangman Fracture
 Definition : C2 bilateral pars interarticularis fractures
 Mechanism is
Hyperextension : leads to fracture of pars interarticularis
secondary flexion : tears PLL and disc allowing
subluxation
 X-ray - show subluxation and fracture
 CT - Study of choice to delineate fracture pattern
 MRA - Consider if suspicious of a vascular injury to the
vertebral artery

21. CT scan cervical. C2 view.
Axial bone view.
Saggital bone view.

22. Source:
Orthobullets

23. a. Non-operative
 Conservative
Indication : Type 1 fractures, <3mm horizontal
Rigid cervical collar x 4-6 weeks
 Closed reduction, followed by halo immobilization for 8-12
weeks
Indications: Type II with 3-5 mm displacement
Type IIA
What is the technique?
Type II use axial traction combined + extension
Type IIA use hyperextension (avoid axial traction in
Type IIA)

24. b. Operative
Reduction with surgical stabilization
Indications:
Type II with > 5 mm displacement and
severe angulation
Type III (facet dislocations)
What are examples of surgical
stabilization techniques?
Anterior C2-3 interbody fusion
Posterior C1-3 fusion
Bilateral C2 pars screw osteosynthesis

25. 3. C2 odontoid process fracture
 Definition : A fracture of the dens of the axis (C2)
 most common fracture of the axis
 occur in bimodal fashion in elderly and young patients
 in elderly :
- often missed, and caused by simple falls
- associated with increased morbidity and mortality
compared to younger patients with this injury
 young patients : result from blunt trauma to head leading
to cervical hyperflexion or hyperextension

26. Anderson and D’Alonzo Classification

27.  X-ray cervical spine
Request for AP, lateral, open-mouth view
Optional views (flexion-extension radiographs)
Fracture pattern best seen on open-mouth
odontoid
 CT - Study of choice for fracture delineation and to
assess stability of fracture pattern
 CT angiogram - Required to determine location of
vertebral artery prior to posterior instrumentation
procedures
 MRI - Indicated if neurologic symptoms present

28.  Nonoperative
Observation : Only in Os odontoideum w/o neurologic
symptoms or instability
Hard cervical orthosis for 6-12 weeks
Indications : Type I, Type II (elderly-not surgical candidates)
and Type III fractures(No evidence to support Halo over hard
collar)
Halo vest immobilization for 6-12 weeks
Indications : Type II young patient with no risk factors for
nonunion
Contraindication : Elderly patients
*do not tolerate halo (may lead to aspiration, pneumonia,
and death)

29. Lower Cervical Spine (Subaxial)
Fractures
 Fractures from C3 to C7
 Tend to produce characteristic fracture patterns,
depending on MOI (e.g.: Flexion, axial compression,
flexion-rotation or hyperextension)
 Characterised as
- Cervical Body Fractures (Compression and Burst)
- Facet dislocations
- Spinous process fractures.

30. 1. Wedge Compression Fracture
► Definition : compressive failure of anterior vertebral body
without disruption of posterior body cortex and without
retropulsion into canal
 Middle and posterior elements remain intact, injury is
stable
 Mechanism: Pure flexion injury
 X-ray cervical spine : Sufficient.
 BUT if any doubt, axial CT/MRI should be ordered.
 Tx: Cervical collar 6-12 weeks. Pain control.

32. 2. ‘Tear-drop’ fractures
 Definition : burst (vertebral body crushed) and compression-
flexion fractures of vertebral body
 Antero-inferior fragment of vertebral body is sheared off,
fracture is unstable
 Risk : Posterior displacement of vertebral body fragment and
spinal cord injury
 Prognosis: Often associated with complete and incompete
spinal cord injury
 Treatment
CRIB, then skull traction for 2-4 weeks
Fracture is usually unstable and requires surgery
* Anterior corpectomy, bone grafiting and plate fixation, with

33. Source: Apley

34. 3. Cervical Facet Dislocations & Fractures
Consists of:
A) Unilateral facet dislocation : Frequently missed cervical spine
injury on plain x-rays
B) Bilateral facet dislocation : Leads to 50% subluxation on x-ray
C) Facet fractures : - More frequently involves superior facet
- May be unilateral or bilateral
D) Facet fracture-dislocation
 Mechanism of Injury: Flexion and distraction forces +/- an
element of rotation

35.  X-ray :
lateral shows subluxation of vertebral bodies
 CT scan :
associated fractures of the pedicle or lamina
 MRI :
disc herniations
extent of posterior ligamentous injury
spinal cord compression or myelomalacia
Should always be performed prior to open reduction or surgical
stabilization
# if a disc herniation is present with compression on the spinal
cord, then you must go anterior to perform a anterior cervical
disectomy

37.  Non-operative
indication : without signifant subluxation, dislocation or kyphosis)
Treatment : cervical orthosis or external immobilization (6-12
weeks)
Menagement

38.  Operative
1. Immediate closed reduction, then MRI, then surgical stabilization
Indications:
Unilateral facet dislocation with deficits in awake and cooperative
patient
Bilateral facet dislocation with deficits in awake and cooperative
patient
2. Immediate MRI then open reduction surgical stabilization
facet dislocations (unilateral or bilateral) in patient with mental
status changes
patients who fail closed reduction

39. Summary of Methods of Treatment of
Cervical Spine Injuries
► Soft collars  minor sprains
 Rigid collars  limit movement after acute injury
 Skull tongs with traction  for # and dislocation.
 Halo rings (attached to skull by 4 pins)  fixed to plaster vest after reduction
of # and dislocation.
 Halo ring fixation  lesser injuries with risk of vertebrae displacement.
 Operative fixation  lag screw (odontoid #), decompression (burst #)
*Choice of treatment depends on expert opinion from specialist

40. Source: Apley’s System of Orthopaedics

41. Skull Tongs
► Indication
subaxial cervical fractures with malalignment
unilateral and bilateral facet dislocations
displaced odontoid fractures
select hangman's fractures
C1-2 rotatory subluxation
 Contraindications
patient who is not awake, alert, and cooperative
 presence of a skull fracture may be a contraindication

42. Patient position
► Preferred setting : emergency room, opearating room, icu for closed
observation and frequent fluoroscopy/radiography
► Patient position : supine with reverse trendelenburg or use of arm and leg
weights can help prevent patient migration to the top of the bed with
addition of weights.
► Sedation : small doses of diazepam can be administered to aid in muscle
relaxation
#however patient must remain awake and able to converse
Pin placement (Gardner-Wells pins)
 pin placement is 1 cm above pinna, in line with external auditory meatus
and below the equator of the skull.

44. Thoracolumbar Injuries

45.  Potentially devastating due to
 Narrow canal
 Precarious blood supply
 fulcrum of motion at thoracolumbar spine
Thoracic spine (T2-T10)
fractures in this region is rare
Why? Due to increased stability of thoracic spine
Protected to some extent by rib-cage
Thoracolumbar region (T11 to L2)
more commonly affected by spine trauma due to fulcrum of
motion (intersection between stiff thoracic spine and increased
motion of lumbar spine)
INTRODUCTION

46. Pathogenesis
3 groups
 Low-energy insufficiency # (mild compressive stress,
OP bone)
 Minor # verterbral process (compressive, tensile,
tortional strains)
 High energy #, #-d/c (major injury, MVA, fall from
height, sport, horse riding, collapsed building)
With Neurological complication

47. Biomechanics
 thoracic spine from T2 to T10 has increased stiffness due to
increased rigidity by articulation with ribs
ribs articulate with sternum, adding secondary stability
facet joints oriented in coronal plane
discs are thin increasing stiffness and rotational stability
kyphosis concentrates axial load on anterior column
 Blood supply
 "watershed area" in middle thoracic spine
vascular injury can lead to cord ischemia
 Spinal cord
 Intersection of spinal cord and cauda equine are at level of L1/L2
injuries below L1 have a better prognosis because the nerve roots (cauda equina and
nerve roots within thecal sac) are affected as opposed to the spinal cord

48. Scottie Dog Sign(normal lumbar
spine)

49. 1. THORACOLUMBAR COMPRESSION
FRACTURE(wedge)
 Most common vertebral fracture
 MOI : Severe spinal flexion
 Posterior ligaments usually remain intact
 Pain usually quite severe, BUT fracture
usually stable

50. Source: Apley

51. Management
 Min. wedging (Loss < 20% anterior vertebral height) and stable injury :
CRIB 1-2 weeks, until pain subside.
 Moderate Wedging (Loss 20-40% anterior vertebral height) and stable
injury:
- TLSO or body cast with back in extension 8-12 weeks
- TCA 3/12: XOA T-L spine, with flexion-extension x-rays
- If no instability, brace gradually discarded
 Severe wedging (Loss anterior vertebral height > 40%) w/out
neurological sign :
- Surgical correction and internal fixation preferred treatment
 Severe wedging and neurological signs (Rare) :
- Operative decompression and stabilization

52. 2. Thoracolumbar Burst Fractures
 Definition : vertebral fracture with compromise of the anterior and middle
column
 can be unstable because both anterior and middle columns are involved
 Mechanism :
 axial loading with flexion
 at thoracolumbar junction there is fulcrum of increased motion that makes
spine more vulnerable to traumatic injury
 Neurologic deficits :
 canal compromise often caused by retropulsion of bone
 maximum canal occlusion and neural compression at moment of impact
 retropulsed fragments resorb over time and usually do not cause progressive
neurologic deterioration
 Associated injuries :
 concomitant spine fractures in 20%

53. CT thoracolumbar spine, sagital
view
CT L3 spine, axial view
X-ray thoracolumbar spine, AP view

54.  Radiographs
 recommended views : entire spine (concomitant spine fractures in 20%)
 AP shows : widening of pedicles + coronal deformity
 lateral shows : retropulsion of bone into canal + kyphotic deformity
 CT scan indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
 MRI useful to evaluate :
spinal cord or thecal sac compression by disk or osseous material
cord edema or hemorrhage
injury posterior ligament complex
#signal intensity in PLC is concerning for instability and may warrant surgical
intervention

55. Non-operative
ambulation as tolerated with or without a thoracolumbosacral
orthosis
indications
 patients that are neurologically intact and mechanically stable
 posterior ligament complex preserved
 kyphosis < 30° (controversial)
 vertebral body has lost < 50% of body height (controversial)
 TLICS score = 3 or lower
# thoracolumbar orthosis
 recent evidence shows no clear advantage of TLSO on outcomes
 if it provides symptomatic relief, may be beneficial for patient
Operative
surgical decompression & spinal stabilization

56. 3. Chance Fracture (flexion-distraction injury)
 Mechanism :
a flexion-distraction injury (seatbelt injury)
may be a bony injury
may be ligamentous injury (flexion-distraction injury)
- more difficult to heal
middle and posterior columns fail under tension
anterior column fails under compression
 Associated injuries :
high rate of gastrointestinal injuries (50%)

57. Source: Orthobullets

58.  Radiographs
obtain AP and lateral
flexion-extension radiographs
 MRI
important to evaluate for injury to the posterior
elements
 CT
important to evaluate degree of bone injury and
retropulsion of posterior wall into canal

59. Nonoperative
immobilization in cast or TLSO
indications
neurologically intact in patients with :
- stable injury patterns with intact posterior elements
- bony Chance fracture
technique
may cast or brace (TLSO) in extension
Operative
surgical decompression and stabilization

60. 4. Thoracolumbar Fracture-Dislocation
 Definition : Fractures associated with posterior facet
dislocation occuring at the thoracolumbar junction (AO type
C)
 Mechanism of injury : acceleration/deceleration injuries
resulting in hyperflexion, rotation and shearing of the
spinal column
 Associated injury :
neurologic deficits
head injury
concomitant injuries in thorax and abdomen

61.  Epidemiology
approx. 4% of spinal cord injuries admitted to Level 1
trauma centres
50-60% of fracture-dislocations are associated with spinal
cord injuries
 Risk factor
high energy injuries
motor vehicle accident (most common)
falls
sports
Violence

62.  Radiographs
 recommended views
 AP and lateral view of thoraco-lumbar spine
 indications
 suspected spinal column injury with bone tenderness
 recognize stable versus unstable spine injuries
 findings
 fracture type, pattern and dislocation
 CT scan
 indications
 better visualization of fracture pattern and type compared to plain radiographs (e.g. unilateral facet
dislocations, etc)
 blunt trauma patients requiring a CT scan to screen for other injuries
 findings
 cannot adequately visualize and describe the spinal canal and other associated ligaments
 MRI
 indications
 better visualisation of the spinal cord and supporting ligamentous structures
 level of neurological deficit does not align with apparent level of spinal injury

63. Operative
posterior open reduction with instrumented
fusion
indications
most patients with thoracolumbar
fracture dislocation
unstable fracture patterns
disrupted supporting ligamentous
structures

64. 5. Osteoporotic Compression Fracture
Definition : A fragility fracture of the spine
Epidemiology :
vertebral compression fractures (VCF) are the most common
fragility fracture
25% people over 70 years and 50% people over 80 years
Associated conditions :
compromised pulmonary function due to increased kyphosis

65.  Radiographs (entire spine - concomitant spine fractures in 20%)
will see loss of anterior, middle, or posterior vertebral height by
20% or at least 4mm
 CT scan (usually not necessary for diagnosis)
Indicated if inadequate plain films
 MRI (usually not necessary for diagnosis)
useful to evaluate :
acute vs chronic nature of compression fracture
injury to anterior and posterior ligament complex
spinal cord compression by disk or osseous material
cord edema or hemorrhage

66. Nonoperative
observation, bracing, and medical management
indications :
PLL intact (even if > 30 degrees kyphosis or > 50% loss of
vertebral body height)
technique :
1. if the fracture is less than five days old
- calcitonin can be used for four weeks to decrease pain
2. medical management can consist of bisphosphonates
- to prevent future risk of fragility fractures
3. some patients may benefit from an extension orthosis
- although compliance can be an issue

67. Case: 81 yr old female, u/l HPT, IHD, H/o Right LACI, 3 hours post- alleged fall
from toilet, fell on sitting position, sustained lower back pain, pain score 7/10,
no radiation, no LL weakness or loss of sensation. BO/PU normal.
O/e: Tenderness over lower lumbar area. No neurological deficit.
X-ray thoracolumbar AP
view
X-ray thoracolumbar,
lateral view

68. Treatment:
 Juvet brace at least 3/52
 TCA Ortho clinic 2/12
 Meds:
T. Fosamax 70 mg weekly
T calcium lactate and calcitriol
Old meds
Get date for DEXA scan

69. References
 Louis Solomon, D. W. (2010). Apley's System of Orthopaedics and Fractures (9 ed.). Florida: CRC Press, pg 805-828
 Maheshwari, J. and Mhaskar, V.A., (2011). Essential orthopaedics. JP Medical Ltd, pg 257- 267
 Keith L. Moore, A. F. (2015). Moore Clinically Oriented Anatomy (7 ed.). Philadelphia: Lippincott Williams and Wilkins, pg 406-
447
 OrthoBullets, https://www.orthobullets.com/
 Atlas (C1) anatomy, Dr Tim Luijkx, https://radiopaedia.org/articles/atlas-c1
 Typical Cervical Vertebrae, Dr Craig Hacking, et al, https://radiopaedia.org/articles/typical-cervical-vertebrae
 www.wikiradiography.net/m/page/Soft+Tissue+Signs+Cervical +Spine