4. INTRODUCTION
• Failure to properly diagnose or manage spine injuries
can result in neurologic deficits that permanently
impair a patient’s function and quality of life and in
some cases, may lead to death.
• Archeological records from more than 4,500 years
ago are noted to forewarn that paralysis is incurable
but today patients with spinal cord injury regain
mobility, improve their quality of life, and achieve
prolonged survival.
5. EPIDEMIOLOGY
• A majority (80%) of patients with spinal cord injury (SCI)
harbor multisystem injuries , typically associated injuries
include other bone fractures (29.3%) and brain injury (11.5%)
.
• Nearly all SCI damage both upper and lower motor neurons
because they involve both the gray matter and descending
white matter tracts at the level of injury.
• The American Spinal Injury Association (ASIA) has suggested
a comprehensive set of standardized clinical measurements
which are based upon a detailed sensory and motor
examination of all dermatomes and myotomes .( Luc et al
2020)
6. ANATOMY OF THE SPINE
Structure of a Vertebrae
• All vertebrae share a basic common structure. They
each consist of an anterior vertebral body, and a
posterior vertebral arch.
• The vertebral body forms the anterior part of each
vertebrae.
7. Anato cont…
• It is the weight-bearing component, and vertebrae in
the lower portion of the column have larger bodies
than those in the upper portion (to better support the
increased weight).
• The superior and inferior aspects of the vertebral
body are lined with hyaline cartilage.
Adjacent vertebral bodies are separated by a
fibrocartilaginous intervertebral disc.
9. Cont…
Spinous processes – each vertebra has a
single spinous process, centred posteriorly at
the point of the arch.
Transverse processes – each vertebra has two
transverse processes, which extend laterally and
posteriorly from the vertebral body.
In the thoracic vertebrae, the transverse
processes articulate with the ribs.
Pedicles – connect the vertebral body to the
transverse processes.
10. Lamina – connect the transverse and spinous
processes.
Articular processes – form joints between one
vertebra and its superior and inferior counterparts.
The articular processes are located at the
intersection of the laminae and pedicles.
11.
12. Anatomy cont……Cervical vertebrae
There are seven cervical vertebrae in the human
body.
They have three main distinguishing features:
Bifid spinous process – the spinous process
bifurcates at its distal end.
Exceptions to this are C1 (no spinous process) and
C7 (spinous process is longer than that of C2-C6 )
13. Occipital-C1-C2 Ligamentous Complex
- Provided by the odontoid process and its supporting
ligaments
o transverse ligament
- limits anterior translation of the atlas
o apical ligaments
- limit rotation of the upper cervical spine
o alar ligaments
- limit rotation of the upper cervical spine
14.
15. Subaxial Cervical Spine (C3 to C7)
C1 to C7
o have a transverse foramen
o vertebral artery travels through transverse foramen of C1 to
C6
C2 to C6
o have bifid spinous process
C6
o contains palpable carotid tubercle which is a valuble
landmark for anterior approach to cervical
spine
C7
o nonbifid spinous process
o despite having a transverse foramen, the vertebral artery
does NOT travel through it in the majority of patients
o there is no C8 vertebral body although there is a C8 nerve
root
OrthoBullets2017
16. UPPER CERVICAL SPINE
Occipital condyle fracture
This is usually a high-energy fracture and associated
skull or cervical spine injuries must be sought.
The diagnosis is likely to be missed on plain X-ray
examination and CT is essential.
Impacted and undisplaced fractures can be
treated by brace immobilization for 8–12 weeks.
Displaced fractures are best managed by using a
halo vest or by operative fixation.
17. C1 ring fracture
An axial load may result in a burst fracture of the
ring of the atlas (Jefferson’s fracture ).
There is seldom a neurological injury.
The fracture is identified on the open-mouth X-ray
view with displacement of C1 relative to C2
A fracture may be visible on the lateral view. A CT
scan will confirm and define the fracture.
If undisplaced, the injury is stable and the patient
is managed with a semi-rigid collar.
18.
19.
20.
21.
22. C2
This is frequently incorrectly referred to as a
‘hangman’s fracture’ Judicial hanging caused the
fracture and death by spinal cord injury due to a
distractive force rather a hyperextension mechanism
causing a resultant anterior translation at C2 which
will results in a pars fracture, sometimes extending
into the posterior body wall and a C2/3 disc
disruption.
Neurological injury is unusual as the pars fractures
expand the canal. Stability is determined by the C2/3
disc status and facet integrity
23. C2 odontoid process fracture
Odontoid fractures are uncommon.
They usually occur as flexion injuries in young
adults after high-velocity accidents they also occur
in elderly, osteoporotic people as a result of low-
energy trauma in which the neck is forced into
hyperextension, such as a fall onto the face or
forehead.
There is seldom neurological injury due to the
large canal size at this level
24. CLASSIFICATION
Odontoid fractures have been classified by Anderson
and D’Alonzo
• Type I – an avulsion fracture of the tip of the odontoid
process due to traction by the alar ligaments.
The fracture is stable (above the transverse ligament)
and unites without difficulty.
• Type II – a fracture at the junction of the odontoid
process and the body of the axis. This is the
most common (and potentially the most dangerous)
type. The fracture is unstable and prone to
non-union.
• Type III – a fracture through the body of the axis.
The fracture is stable and almost always unites with
immobilization
25.
26. TREATMENT
Type I Fractures- Isolated fractures of the odontoid
tip are stable. They need no more than immobilization
in a rigid collar until discomfort subsides.
Type II fractures- These are often unstable and prone to non-
union, especially if displaced more than 4 mm, tilted more than
11 degrees, in older patients and in smokers.
In the young patient with an undisplaced fracture,union is
anticipated. Management can be non-operative with a period
of traction followed by collar or halo vest. In the very elderly, a
collar is appropriate due to the poor risk-to-benefit ratio of
surgery.
27. Type III Fractures- Undisplaced fractures are treated
in a halo vest for 8–12 weeks. If displaced, attempts
should be made at reducing the fracture by halo
traction
28. LOWER CERVICAL SPINE
Fractures of the cervical spine from C3 to C7
(subaxial cervical spine) tend to produce
characteristic fracture patterns, depending on the
mechanism of injury.
Many classification systems were developed
including the Ferguson and Allen classification
30. Burst and ‘teardrop’ fractures
(compressive flexion mechanism)
These severe injuries are due to axial compression
of the cervical spine with flexion, usually in diving
or athletic accidents. A fall down while carrying a
luggage on the head
If the vertebral body is crushed in neutral position
of the neck, the result is a ‘burst fracture’.
With an increasing flexion moment, the
anteroinferior fragment of the vertebral
body is sheared off, producing the eponymous
‘teardrop”on the lateral X-ray.
31.
32.
33.
34. Thoracic…
The twelve thoracic vertebrae are medium-sized,
and increase in size from superior to inferior.
Their specialised function is to articulate with ribs,
producing the bony thorax.
Each thoracic vertebra has two ‘demi facets,’
superiorly and inferiorly placed on either side of its
vertebral body.
The demi facets articulate with the heads of two
different ribs.
35. Cont…
• On the transverse processes of the thoracic
vertebrae, there is a costal facet for articulation
with the shaft of a single rib.
• For example, the head of Rib 2 articulates with
the inferior demi facet of thoracic vertebra (T1)
and the superior demi facet of T2, while the shaft
of Rib 2 articulates with the costal facets of T2.
36.
37. Lumbar…..
They are structurally specialised to support the
weight of the body
Lumbar vertebrae have very large vertebral
bodies.
They are kidney shaped.
They lack the characteristic features of other
vertebrae, with no transverse foramina, costal
facets, or bifid spinous process
38. Blood Supply
Spinal cord blood supply provided by;
anterior spinal artery
primary blood supply of anterior 2/3 of spinal
cord, including both the lateral corticospinal tract
and ventral corticospinal tract
posterior spinal artery (right and left)
primary blood supply to the dorsal sensory
columns
39. Ctn…..
Artery of Adamkiewicz
- the largest anterior segmental artery
- typically arises from left posterior intercostal artery, which
branches from the aorta, and supplies the lower two thirds of the
spinal cord via the anterior spinal artery
- significant variation exists
- in 75% it originates on the left side between the T8 and L1
vertebral segments
40.
41. DENIS THREE COLUMN
Denis divided the vertebral column into 3 vertical parallel
columns based on biomechanical studies related to stability
following traumatic injury.
Instability occurs when injuries affect 2 contiguous columns
(i.e. anterior and middle column or middle and posterior
column). Obviously a 3 column injury is also unstable.
Anterior column:
• anterior longitudinal ligament (ALL)
• anterior two-thirds of the vertebral body
• anterior two-thirds of the intervertebral disc (annulus
fibrosus)
42. Cont…
middle column:
• posterior one-third of the vertebral body
• posterior one-third of the intervertebral disc
(annulus fibrosus)
• posterior longitudinal ligament (PLL)
posterior column:
• everything posterior to the PLL
• pedicles
• facet joints and articular processes
• ligamentum flavum
• neural arch and interconnecting ligamen
45. Joints and ligaments
Two ligaments strengthen the vertebral body
joints:
The anterior and posterior longitudinal ligaments,
which run the full length of the vertebral column.
The anterior longitudinal ligament is thick and
prevents hyperextension of the vertebral column.
The posterior longitudinal ligament is weaker and
prevents hyperflexion.
46.
47. Cont……
The mobile vertebrae articulate with each other
via joints between their bodies and articular
facets:
Left and right superior articular facets articulate
with the vertebra above.
Left and right inferior articular facets articulate with
the vertebra below.
Vertebral bodies indirectly articulate with each
other via the intervertebral discs
48. • The length of the vertebral column averages 72 cm
in men and 7 to 10 cm less in women.
• The vertebral canal extends throughout the length
of the column and provides protection for the spinal
cord, conus medullaris, and cauda equina. The
spinal cord is shorter than the vertebral column and
terminates as the conus medullaris at the second
lumbar vertebra in adults and the third lumbar
vertebra in neonates.
• From the conus, a fibrous cord called the filum
terminale extends to the dorsum of the first
coccygeal segment.
49. Cont…
• Spinal nerves exit the canal at each level. Spinal
nerves C2-7 exit above the pedicle for which they
are named (the C6 nerve root exits the foramen
between the C5 and C6 pedicles).
• The C8 nerve root exits the foramen between the
C7 and T1 pedicles. All spinal nerves caudal to C8
exit the foramen below the pedicle for which they
are named (the L4 nerve root exits the foramen
between the L4 and L5 pedicles).
50. Cont…
• Each level gives off a dorsal (sensory) root and a
ventral (mostly motor) root, which combine to form
the mixed spinal nerve.
• The dorsal root of each spinal nerve has a ganglion
located near the exit zone of each foramen.
• This dorsal root ganglion is the synapse point for
the ascending sensory cell bodies.
.
51. Cont…
• The spinal cord is enclosed in three
protective membranes.
• The pia, arachnoid, and dura mater. The pia
and arachnoid membranes are separated by
the subarachnoid space, which contains the
cerebrospinal fluid.
• The spinal cord has enlargements in the
cervical and lumbar regions that correlate
with the brachial plexus and lumbar plexus.
52.
53.
54.
55.
56. Associated conditions
o acute phase conditions
spinal shock
neurogenic shock
o associated injuries
vertebral artery injury
risk factors for vertebral artery injury include
atlas fractures
facet dislocations
most people with unilateral injury remain asymptomatic
Imaging magnetic resonance angiography is least invasive
method
57.
58.
59.
60. Cont….
• In a biological context ROS and RNS are
byproducts of the normal metabolism of
O2
• Have roles in cell signaling and
homeostasis
• They present in low and stationary levels
in normal cells
63. pyramids
• The medullary pyramids contain motor fibers that are
known as the corticobulbar and corticospinal tracts
• The corticospinal tracts are on the anterior surface of the
pyramids
• These tracts transport motor signals that originated in
the precentral gyrus and travelled through the internal
capsule to the medulla oblongata.
• These fibers decussate at the level of Medulla Oblongata to
form lateral corticospinal tract (90%)
• while the fibers that do not decussate will travel down the
anterior corticospinal tract (10%)
68. Myotomes :
• Segmental nerve root innervating a muscle
• Again important in determining level of injury
• Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Abduction of Small hand muscles
74. MECHANISM OF SPINAL CORD INJURY
Terminologies of SCI
• Neural tissue injuries are divided into two broad etiology
based categories:
• Primary injury refers to physical tissue disruption caused by
mechanical forces and secondary injury refers to additional
neural tissue damage resulting from the biologic response
initiated by the physical tissue disruption.
• The extent of structural damage to neural tissue is indicated
by other descriptive terms:
• Concussion refers to physiologic disruption without anatomic
injury.
• Contusion refers to physical neural tissue disruption leading
to hemorrhage and swelling (the most common type of spinal
cord injury).
75. Ct with mechanism of injury…….
• Laceration refers to loss of structural continuity of
the neural tissue (rare in blunt trauma).
• The clinical response to injury is typically described
in temporal terms:
• Acute refers to the first few hours after injury; sub
acute refers to several hours to days following injury,
and chronic refers to intervals of weeks to months
after the injury.
• Complete spinal cord injury, incomplete injury, or
transient spinal cord dysfunction describe different
grades of severity of neurologic injury.
82. Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is
irreversible
ii) Loss of sensation
83. Incomplete:
i) Some function is present below the site
of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury,
although they are rarely pure and
variations occur
84. ASIA IMPAIRMENT
•ASIA Impairment Scale
Motor Sensory
A Complete No motor function Complete deficit
B Incomplete No motor function Incomplete deficit
C Incomplete
Motor function partially
preserved: more than half
of key muscles below the
neurological level have a
muscle grade less than 3.
Incomplete deficit
D Incomplete
Motor function is partially
preserved - at least half of
key muscles below the
neurological level have a
muscle grade of 3 or
more.
Incomplete deficit
E Normal Normal motor Normal sensory
85. Spinal Shock vs Neurogenic Shock
Spinal Shock :
• Transient reflex depression of cord function below level
of injury
• Initially hypertension due to release of catecholamines
• Followed by hypotension
• Flaccid paralysis
• Bowel and bladder involved
• Sometimes priaprism develops
• Symptoms last several hours to days
86. Bulbocarvenosus reflex
• The bulbocavernosus reflex refers to
contraction of the anal sphincter in response
to stimulation of the trigone of the bladder
with either a squeeze on the glans penis, a
tap on the mons pubis, or a pull on a urethral
catheter.
• The absence of this reflex indicates spinal
shock
87. Neurogenic shock:
• Triad of i) hypotension
ii) bradycardia
iii) hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic
outflow from T1 – L2
88. • Loss of vasomotor tone – pooling of blood
• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid
infusion alone
• Massive fluid administration may lead to
overload and pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
89. Types of incomplete injuries
i) Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome
90. 1.Central Cord Syndrome
• most common incomplete cord injury
• often in elderly with minor extension
injury mechanisms
– due to anterior osteophytes and posterior
infolded ligamentum flavum
92. Central Cord Syndrome
Pathophysiology
• believed to be caused by spinal cord compression and
central cord edema with selective destruction of lateral
corticospinal tract white matter
• anatomy of spinal cord explains why upper extremities
and hand preferentially affected
– hands and upper extremities are located "centrally" in
corticospinal tract
93. Central Cord Syndrome
• Presentation
– weakness with hand dexterity most affected
– loss
• motor deficit worse in UE than LE
• hands have more pronounced motor deficit than arms
– preserved
• sacral sparing
• late clinical presentation
– UE have LMN signs (clumsy)
– LE has UMN signs (spastic)
94. Central Cord Syndrome
• recovery occurs in typical pattern
– lower extremity recovers first
– bowel and bladder function next
– proximal upper extremity next
– hand function last to recover
95. Treatment
• nonoperative vs. operative
– extremely controversial
• Prognosis final outcome
– good prognosis although full functional recovery rare
– usually ambulatory at final follow up
– usually regain bladder control
– upper extremity and hand recovery is unpredictable
and patients often have permanent clumsy hands
96. ii) Anterior cord Syndrome
• Motor dysfunction
• dissociated sensory deficit below level of SCI
• injury to anterior spinal cord caused by
– direct compression (osseous) of the anterior spinal
cord which is related to flexion injuries of cervical
region and result in infarction 2/3 of the cord
– anterior spinal artery injury
• anterior 2/3 spinal cord supplied by anterior spinal
artery
97. Anterior cord Syndrome
Clinically:
• Loss of power
• Decrease in pain and sensation below
lesion
• Dorsal columns remain intact
• worst prognosis of incomplete SCI
98.
99.
100. 2. Posterior Cord Syndrome:
Hyperextension injuries with fractures
of the posterior elements of the vertebrae
Clinically:
• Proprioception affected – ataxia and
faltering gait
• Usually good power and sensation
101.
102. 4 Brown – Sequard Syndrome:
• Hemi-section of the cord
• Either due to penetrating injuries:
i) stab wounds ii) gunshot wounds
Fractures of lateral mass of vertebrae
Clinical features:
• Paralysis on affected side (corticospinal)
• Loss of proprioception and fine
discrimination (dorsal columns)
• Pain and temperature loss on the opposite
side below the lesion (spinothalamic )
102
103. 5. Cauda Equina Syndrome:
• Due to bony compression or disc protrusions
in lumbar or sacral region below L3
Clinically
• Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness.
Flaccid hypotonic areflexia paralysis producing
peripheral paraplegia
104.
105.
106. CLINICAL EVALUATION
Patient assessment is a crucial role:
• Airway, breathing, circulation, disability, and exposure
(ABCDE)
• Initiate resuscitation: Address life-threatening injuries.
Maintain rigid cervical immobilization.
• Tracheal intubation and central line placement are often
performed in the emergency setting.
• Evaluate the level of consciousness and neurologic impair
• 5. Assess head, neck, chest, abdominal, pelvic, extremity
injury.
• 6. Ascertain the patient’s history: mechanism of injury
• 7. Physical examination
107. Cont…..
• Neurologic examination includes:
• Cranial nerves
• Complete sensory and motor examination
• Upper and lower extremity reflexes
• Rectal examination: perianal sensation, rectal
tone
• Bulbocavernosus reflex
• Dermatomes and myotomes
108. RADIOLOGICAL EVALUATION
• Patients complaining of neck pain should
undergo complete radiographic evaluation of the
cervical spine, including anteroposterior (AP)
odontoid view,and lateral views.
• Assess for Continuity of radiographic “lines”
• anterior vertebral line, posterior vertebral line,
facet joint line, or spinous process line
• Widening or narrowing of disc space
• CT SCAN as gold standard for spine fractures
• MRI is also indicated
109. MRI
• MRI are Used in .
• Detecting traumatic
• disc herniation,
• epidural hematoma,
• spinal cord edema or compression,
• and posterior ligamentous disruption.
• An additional application of MRI is the ability to
visualize vascular structures. MR arteriograms
can be used to assess the patency of the
vertebral arteries.
113. RADIOLOGICAL EVALUATION
• Patients complaining of neck pain should
undergo complete radiographic evaluation of the
cervical spine, including anteroposterior (AP)
odontoid view,and lateral views.
• Assess for Continuity of radiographic “lines”
• anterior vertebral line, posterior vertebral line,
facet joint line, or spinous process line
• Widening or narrowing of disc space
• CT SCAN as gold standard for spine fractures
• MRI is also indicated
114. In conclusion;
Spinal Cord Injuries:
• Devastating event to both patient and
family.
• Huge impact on society
• After receiving First – World care in
tertiary institutions, many of our
patients return to impoverished
communities
• Here they face huge challenges in terms
of survival
115. REFERENCES
• Study done in Botswana in 2015 by Löfvenmark et al To describe
the epidemiology of traumatic spinal cord injuries (TSCIs) in
Botswana, with a specific focus on road traffic crash.
• Campbell 11th ed
• Rookwood fractures in Adult
• Handbook fractures
• Teachme anatomy
• The principle of the advanced trauma life support(ATLS) framework
in spinal trauma article August 2020
• Protocol ORU SCI for physiotherapy
