cervical spine injury

1. S U R A I N R A A J T H A N G A T H U R A I
CERVICAL SPINE INJURY

2. ANATOMY

5. ANATOMY
5
http://www.radiologyassistant.nl/
en/p4906c8352d8d2/spine-
thoracolumbar-injury.html
Dennis three column
-instability occur when
Injury occur 2
contiguous column(ie
anterior and middle or
middle and posterior
column)

7. CERVICAL SPINE INJURY –
MECHANISMS OF INJURY
flexion
flexion-rotation
extension
extension-rotation
vertical compression

8. FLEXION INJURY
• Common injuries associated
with a flexion mechanism
include the following:
-Simple wedge compression
fracture without posterior
disruption
-Flexion fracture
-Anterior subluxation
-Bilateral facet dislocation
-Anterior atlantoaxial dislocation

9. ANTERIOR SUBLUXATION
• Occurs when posterior ligamentous
complexes rupture. The anterior
longitudinal ligament remains intact.
No bony injury is seen.
• The lateral view Xray shows widening
of interspinous process. Since the
anterior columns remain intact, this
fracture is considered mechanically
stable.

10. BILATERAL FACET DISLOCATION
• Extreme form of anterior
subluxation that occurs
when a significant degree
of flexion and anterior
subluxation causes
ligamentous disruption to
extend anteriorly

11. FLEXION-ROTATION INJURY
• Unilateral facet dislocation
• stable fracture.
• Anterior displacement of
spine is less than one half
diameter of vertebral body

12. EXTENSION INJURY : HANGMAN
FRACTURE
• commonly caused by
motor vehicle collisions
• bilateral fractures pedicles
of C2 due to
hyperextension.
• Potentially unstable

14. VERTICAL (AXIAL) COMPRESSION
INJURY
• Burst fracture of the
vertebral body
• Usually in diving or athletic
accidents

15. SPINAL CORD INJURIES
• Insult to spinal cord resulting in a change in the
normal motor, sensory or autonomic function. This
change is either temporary or permanent.
• All spinal cord injuries are divided into two
categories: incomplete and complete.

16. TYPES OF SPINAL CORD INJURIES
Incomplete
the cord is only partially
severed, allowing the
injured person to retain
some function
With incomplete injuries,. In
these cases, the degree of
function depends on the
extent of the injuries
Complete
fully severed
with treatment and physical
therapy, it may be possible
to regain some function.

18. TYPES OF INCOMPLETE OR PARTIAL
SPINAL CORD INJURIES INCLUDE
Anterior cord syndrome
•This type of injury, to the
front of the spinal cord
•Motor paralysis, loss of
pain and temperature below
level of lesion.
Proprioception and vibration
intact.
Central cord syndrome
• injury to the center of the
cord
• Loss of fine motor skills,
paralysis of the arms, and
partial impairment, usually
less pronounced in the
legs are common. Some
survivors also suffer a loss
of bowel or bladder control

19. Brown-Sequard syndrome
•Result in paralysis and loss
of proprioception on
ipsilateral side of body and
loss of sensation(pain and
temperature) in the
contralateral side
Posterior cord syndrome
•affecting posterior column
(fine touch, vibration,
proprioception, pressure)

20. HIGH-CERVICAL NERVES (C1 – C4)
• Inability to breathe without assistance from a ventilator
• Inability or reduced ability to speak
• Loss of feeling or sensation below the level of injury
• Paralysis in the arms, hands, trunk, and legs
• Limited neck and/or head movement

21. LOWER CERVICAL NERVES C5-C8
• Corresponding nerves control arms and hands.
• A person with this level of injury may be able to breathe
on their own and speak normally

22. NEUROGENIC SHOCK
• Temporary loss of autonomic function of the cord at the
level of injury
• results from cervical or high thoracic injury
• Presentation
• Flaccid paralysis distal to injury site
• Loss of autonomic function
• hypotension
• vasodilatation
• loss of bladder and bowel control
• loss of thermoregulation
• warm, pink, dry below injury site
• bradycardia

23. TRIAD FOR NEUROGENIC SHOCK
• Triad
i) hypotension
ii) bradycardia
ii) Hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic outflow from T1 –
L2

24. TREATMENT
Airway management
Cervical spine immobilization
Hemodynamic stabilization
• 1st line – intravenous fluid resuscitation
• 2nd line – Vasopressor ( noradrenaline)
• Recommnd to keep MAP 85-90 to to improve spinal perfusion
• For bradycardia- atropine
• Use of steroid (methylprednisolone, corticosteroid) Controversial-risk of
infection,GI bleed

25. SPINAL SHOCK
• The direct force applied to the spinal cord results in a
physiologic block to conduction (called spinal shock),
which is recognized clinically as complete cessation of
all neurologic function—motor, sensory, and
autonomic—below the level of the injury (complete or
incomplete spinal cord injury).
• a spinal cord injury which usually involves 24-72 hours
period of immediate temporary loss of total power,
sensation and reflexes below the level of injury
• Spinal shock refers to the In slight injuries, this phase
lasts only minutes, but in more severe injuries, it may last
weeks.

26. CHARACTERISTIC OF SPINAL
SHOCK
• Motor Effects – Paraplegia or Quadriplegia
• Loss of tone -Muscles become flaccid
• Areflexia - All superficial and deep reflexes are lost
• Sensory Effects -All Sensations are lost below the
level of transection

27. FEATURES OF SPINAL SHOCK
• Hypotension
• Hypothermia
• Bradycardia
• Flaccid paralysis
• Loss of sensation
• Areflexia or depressed reflexes
• Urinary and bladder incontinence
• Sweating
• Sometimes priapism

28. • Assessment of the end of spinal shock is
based on the return of reflexes, with the
bulbocavernosus reflex typically being the
first to return.
• The diagnosis of complete or incomplete
spinal cord injury cannot be made until the
period of spinal shock is over.

29. PROGNOSTIC FACTORS OF
NEUROLOGICAL RECOVERY
Good prognostic factor
• 1.Spinal shock of <24 hours and
• 2.Early appearance of deep tendon reflexes
Poor prognostic factor
• 1.Complete lesion
• 2.Spinal shock for >1 week,
• 3.Flexor spasms within three weeks
• 4. Bedsore within one week

30. SPINAL V/S NEUROGENIC SHOCK
Spinal shock Neurogenic shock
Definition Immediate temporary loss of
total power, sensation and
reflexes below the level of
injury
Sudden loss of the
sympathetic nervous system
signals
BP Hypotension Hypotension
Pulse Bradycardia Bradycardia
Bulbocavernosu
s reflex
Absent Variable
Motor Flaccid paralysis Variable
Time 48-72 hrs immediate after SCI
Mechanism Peripheral neurons become
temporarily unresponsive to
brain stimuli
Disruption of autonomic
pathways → loss of
sympathetic tone and
vasodilation

31. CERVICAL SPINE EXAMINATION
• Inspection and palpation
• Occiput to Cervical
• Soft tissue swelling and bruising
• Point of spinal tenderness
• Gap or Step-off
• Spasm of associated muscles
• Neurological assessment
• Motor, sensation and reflexes
• Cranial nerve examination should always be
performed.
• PR

33. RADIOGRAPHIC IMAGING
✓NEXUS -The National Emergency X- Radiograph
Utilization Study
• Prospective study to validate a rule for the decision to obtain cervical
spine x- ray in trauma patients
• Hoffman, N Engl J Med 2000; 343:94-99
✓Canadian C-Spine rules
• Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a decision as to
the need for subsequent cervical spine radiography
• Stiell I. JAMA. 2001; 286:1841-1846

34. NEXUS
• NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain

35. NEXUS
• Patient who fulfilled all 5 of the criteria were
considered low risk for C-spine injury
→ No need C-spine X-ray
• For patients who had any of the 5 criteria
→ radiographic imaging was indicated
( AP, lateral and open mouth views)

36. THE CANADIAN C-SPINE RULE FOR ALERT AND STABLE TRAUMA PATIENTS
WHERE CERVICAL SPINE INJURY IS A CONCERN.
• Any high-risk factor that mandates radiography?
• Age>65yrs or
• Dangerous mechanism or
• Paresthesia in extremities
Any low-risk factor that allows safe
assessment of range of motion?
• Ambulatory at any time, or
• Delayed onset of neck pain, or
• Absence of midline C-spine tenderness
Able to actively rotate neck?
• 45 degrees left and right
No Radiography
Radiography
NO
YES
ABLE
YES
NO
UNABLE

37. CERVICAL SPINE IMAGING OPTIONS
• Plain films
• AP, lateral and open mouth view
• Optional: Oblique and Swimmer’s , odontoid
• CT
• Better for occult fractures
• MRI
• Very good for spinal cord, soft tissue and
ligamentous injuries
• Flexion-Extension Plain Films
• to determine stability

38. RADIOLOGRAPHIC EVALUATION
X-ray Guidelines (cervical)
AABBCDS
• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue

39. ADEQUACY
• Must visualize entire C-spine
• A film that does not show the upper
border of T1 is inadequate
• Caudal traction on the arms may
help
• If can not, get swimmer’s view or
CT

40. SWIMMER’S VIEW

41. ALIGNMENT
• The anterior vertebral
line, posterior vertebral
line, and spinolaminar
line should have a
smooth curve with no
steps or discontinuities
• Malalignment of the
posterior vertebral
bodies is more
significant than that
anteriorly, which may
be due to rotation
• A step-off of >3.5mm is
significant anywhere

42. DISC
• Disc Spaces
• Should be uniform
• Assess spaces
between the spinous
processes

43. LATERAL CERVICAL SPINE X-
RAY
• Anterior subluxation of one vertebra
on another indicates facet dislocation
• < 50% of the width of a vertebral body
→ unilateral facet dislocation
• > 50% → bilateral facet dislocation

44. BONES

45. SOFT TISSUE
• Nasopharyngeal space
(C1)
• 10 mm (adult)
• Retropharyngeal space
(C2-C4)
• 5-7 mm
• Retrotracheal space
(C5-C7)
• 14 mm (children)
• 22 mm (adults)

46. AP C-SPINE FILMS
• Spinous processes should
line up
• Disc space should be
uniform
• Vertebral body height
should be uniform. Check
for oblique fractures.

47. OPEN MOUTH VIEW
• Adequacy: all of the
dens and lateral
borders of C1 & C2
• Alignment: lateral
masses of C1 and C2
• Bone: Inspect dens for
lucent fracture lines

48. CT SCAN
• Thin cut CT scan should be
used to evaluate abnormal,
suspicious or poorly
visualized areas on plain film
• The combination of plain film
and directed CT scan
provides a false negative rate
of less than 0.1%

49. MRI
• Ideally all patients with
abnormal neurological
examination should be
evaluated with MRI scan

50. • https://www.spinalcord.com/types-of-spinal-cord-injuries
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989526/
• https://emedicine.medscape.com/article/824380-overview#a7
• https://www.slideshare.net/drsundarkarki/spinal-injury-dr-
sundar-karki

51. THANK YOU