spinal cord inj.

Spinal Cord Injuries
Ahmed Al-sum R I

Content
• Causes
• Anatomy
• Stability
• Classification
• Clinical feature
• Diagnosis
• Management
• Disposition

Causes
• MVC 40%
• Falls
• Violence ( GSW )
• Sporting activities
Male
80%
Female
20%

causes of SCI
Fructure
85%
peurly
ligamintus inj
10%
SCIWORA
5%
Fructure peurly ligamintus inj SCIWORA

Stability
• Resistance to displacement of fracture
fragments or, the entire vertebral unit ,
(in the case of ligamentous injury)
• It may occur at the time of injury or
progressively over hours to weeks and
can cause or worsen damage to the
spinal cord or nerve roots

Stability
• The anterior column is
formed by alternating
vertebral bodies and
intervertebral disks
surrounded by the
annulus fibrosus
capsule and the
anterior longitudinal
ligament.

• The middle column
consists of the posterior
part of the annulus
fibrosus and posterior
vertebral wall, the
posterior longitudinal
ligament, the spinal cord,
the paired laminae and
pedicles, the articulating
facets, the transverse
processes, and the nerve
roots and vertebral
arteries and veins
Stability

Stability
• The posterior column
consists of the spinous
processes, nuchal
ligament, interspinous
and supraspinous
ligaments, and
ligamentum flavum.

Stability
• Disruption of only a
single column usually
preserves a high degree
of stability but does not
preclude SCI from
displaced fracture
fragments.
• Disruption of two
columns results in an
injury that is stable in
one direction but
unstable in another
(e.g., stable in flexion
but unstable in
extension)
• Disruption of all three
columns produces a
highly unstable
• injury.

Stability
• All spinal injuries
should be treated as
potentially unstable,
and spinal
immobilization
should be maintained

Classification of SCI By Mechanism
Flexion
Flexion
rotation
Extension
Vertical
Compression

Flexion
Pure flexion injuries of C1-C2
• Aatlanto-occipital or
• Atlantoaxial joint
dislocation
• with or without # of
odontoid
• UNSTABLE because of
their location and the
relative lack of muscle
and ligamentous
support

Flexion
Pure flexion injuries of C1-C2

Flexion
SIMPLE WEDGE #
Pure flexion injuries below C2
• Because the posterior
column intact, this
injury is usually
STABLE and rarely
cause damage.
• However, spinal
instability may occur
with sever Wedge #

Flexion
SIMPLE WEDGE #
• Radiographically, there
is a diminished height
and increased
concavity of the
anterior border of the
vertebral body, an
increased density of
the vertebral body, and
prevertebral soft
tissue swelling

Flexion
Flexion Teardrop #
• Because this injury
commonly involves
anterior and posterior
ligamentous
disruption, it is often
associated with
neurologic injury and
is highly UNSTABLE

Flexion
Clay Shoveler’s #
• Abrupt head flexion
against the
supraspinous ligament
resulted in an avulsion
fracture of the spinous
process.
• Because this injury
involves only the
spinous process, it is
STABLE

Flexion
Pure Spinal Subluxation
• occurs when the
ligamentous
complexes rupture
without an associated
bony injury.
• rarely associated with
neurologic damage,
this injury is
potentially UNSTABLE.

Flexion
Pure Spinal Subluxation The LRG of neck
• Neutral position may
show a widening of
both interspinous and
intervertebral spaces
posteriorly at the level
of injury,
• Oblique views may
demonstrate a
widening or abnormal
alignment of the facets

Flexion
Pure Spinal Subluxation The LRG of neck
• These findings are
often subtle and may
be missed if flexion
and extension views
are not obtained.

Flexion
Bilateral facet dislocations
• occur when a greater
force of flexion causes
soft tissue disruption to
continue anteriorly to the
annulus fibrosis of the
intervertebral disk and
the anterior longitudinal
ligament.
• It’s an extremely
UNSTABLE condition.

Flexion
Bilateral facet dislocations
• Radiographically the
anterior displacement
will appear to be greater
than one half of the AP
diameter of the lower
vertebral body with the
superior facets anterior
to the inferior facets

Flexion
Shear Injury Type I
• # of the odontoid process
above the transverse
ligaments
• usually STABLE because
they are an avulsion
injury to the odontoid tip.
• BUT , if traction injure the
apical and alar ligaments,
then may become
UNSTABLE

Flexion
Shear Injury Type II
• # at the base of the
odontoid process
where it attaches to
C2.
• More common
• UNSTABLE and often
complicated by
nonunion. SCI is
uncommon but can
occur

Flexion
Shear Injury Type III
• Slight angulation of the
force may result in
extension of the fracture
into the body of C2.
• Mechanically
UNSTABLE as they can
extend laterally into the
superior articular facet of
the atlas.

Flexion-Rotation
Rotary Atlantoaxial Dislocation
• UNSTABLE injury
• visualized best on open-
mouth odontoid radiographs

Flexion-Rotation
Unilateral Facet Dislocation
• both flexion and rotation
• Simultaneous flexion and
rotation cause the
contralateral facet joint to
dislocate.
• The dislocated articular
mass is mechanically
locked in place, making
this a STABLE injury

Extension
Posterior Neural Arch # of C1
• Compression of the
posterior elements
between the occiput and
the spinous process of
C2 during forced neck
extension.
• This fracture is
potentially UNSTABLE
because of its location.

Extension
Hangman’s fracture
• Cervicocranium is
thrown into extreme
hyperextension as a
result of abrupt
deceleration.
• Bilateral # of the
pedicles of C2 W or
WO dislocation.

Extension
Hangman’s fracture
• Although this lesion is
UNSTABLE, cord
damage is often
minimal because the
AP diameter of the
neural canal is
greatest at the C2 level

Extension
Extension Teardrop Fracture
• occurs when abrupt
extension of the neck
• Often occurring in
lower cervical
vertebrae (C5-C7) from
diving accidents
• May be associated
with a central cord
syndrome

Extension
Extension Teardrop Fracture
• Because the posterior
elements remain
intact, this injury is
STABLE in flexion but
potentially UNSTABLE
in extension.

Vertical Compression
Burst Fracture
• occur in the cervical
and lumbar regions,
which are capable of
straightening at the
time of impact.
• It’s is a STABLE
fracture because all
ligaments remain
intact

• However, fracture
fragments may
impinge on or
penetrate the ventral
surface of the spinal
cord and cause an
anterior cord
syndrome

Burst Fracture
• The lateral radiograph
shows a comminuted
vertebral body, and
there will typically be
greater than 40%
compression of the
anterior vertebral body
which help in
differentiation between
simple Wedge #.

Jefferson fracture of C1
• Vertical compression
force drives the lateral
masses of C1 outward,
resulting in fractures
of the anterior and
posterior arches of the
atlas and a disruption
of the transverse
ligament.
• Extremely UNSTABLE
injury.

• Often associated with
prevertebral hemorrhage
and retropharyngeal
swelling.
• lateral film may
demonstrate a widening
of the predental space
between the anterior
arch of C1 and
• the odontoid.

• The open-mouth view
will demonstrate a
bilateral offset of both
right and left lateral
masses of C1 more
than 7mm.
• The Jefferson fracture
is difficult to
recognize, and (CT)
may be necessary.

Classification of SCI By Etiology
Primary Secondary

Primary Spinal Cord Injury
• FIRST
• Penetrating trauma
• Massive blunt trauma with disruption
of the vertebral column may cause
the transection of neural elements.
• such injuries are IRREVERSABLE
• Less severe blunt trauma may have
similar effects resulting from a
displaced bony fragment or a
herniated disk.

• SECOND
• In elderly patients with
osteoarthritis and
spondylosis when subjected
to forcible cervical spine
extension
• This injury frequently results
in a central cord syndrome.

• THIRED
• Primary vascular damage to
the spinal cord.
• Compressed by an
extradural hematoma.
• discrepancy between the
neurologic deficit and the
known level of spinal injury

Secondary Spinal Cord Injury
• The maximum neurologic deficit after
blunt SCI Often not seen immediately
and may progress over hour.
• It is now thought that primary SCI
initiates a complex cascade of
biochemical events that result in
progressive ischemia of gray and white
matter during the postinjury period .
• Other factors, such as hypoxia,
hypotension, hyperthermia,
hypoglycemia, and mishandling by
medical personnel, also affect the
ultimate extent of SCI

NEUROLOGIC EVALUATION
• Hx
• Talk to the pt.
• pain in the sensory dermatome
corresponding to the injured spinal
level .
• C2 lesion may cause occipital
pain.
• discomfort in the trapezius
muscle, suggests a C5 injury. in
the absence of signs of local trauma

• Hx
• PMH.
• Down Syndrome predisposed to
atlanto-occipital dislocation,
• Rheumatoid Arthritis are prone to
rupture of the transverse ligament of
C2.

• Inspection
• Significant head and facial trauma have
a 5 to 10% incidence of associated
cervical spine injuries .
• Scapular contusions suggest a rotation
or flexion-rotation injury of the thoracic
spine.
• Seat-Belt sign associated W carotid ,
vertebral and intra- abdominal inj.

• Inspection
• In case of fall inj.
• injuries to the gluteal region,
calcaneal fractures, and severe
ankle fractures suggest a
compression type of spinal injury.

• Inspection
• abnormal abdominal breathing pattern
may provide an important clue to a
cervical injury.
• Horner’s syndrome, (unilateral ptosis,
miosis, and anhidrosis) may result from
disruption of the cervical sympathetic
chain, usually between C7 and T2.
• Priapism may occur with severe SCI,
and it is often associated with spinal
shock.

• Palpation
• areas of tenderness, deformity, or
muscle spasm.
• A “gibbus” deformity or step-off may be
appreciated with severe subluxation.
• Widening of an interspinous space
indicates a tear in the posterior
ligament complex and a potentially
unstable spinal injury.

• Motor Examination
• rapid baseline assessment.
• When a deficit is noted, the motor and
neurologic examination should be
repeated at frequent intervals because
progression of dysfunction may occur.

• Sensory Examination
• An accurate baseline sensory
examination is imperative because a
cephalad progression of hypesthesia is
the most sensitive indicator of
deterioration.
• When this is observed in the cervical
region, should anticipate impending
respiratory failure and stabilize the
airway

Complete Spinal Cord Lesions
• Total loss of motor power and sensation
distal to the site of an SCI.
• Functional motor recovery is rare in a
patient with a complete cord syndrome
that persists for longer than 24 hours after
the inj.
• Before diagnosis of a complete cord
syndrome, however, two points should be
considered

• First:
• any evidence of minimal cord function,
such as sacral sparing, excludes the
patient from this group.
• Signs of sacral sparing include
perianal sensation, normal rectal
sphincter tone, or flexor toe
movement.
• The presence of any of these signs
indicates a partial lesion, usually a central
cord syndrome, and the patient may have
marked functional recovery,

• Second:
• complete spinal cord lesion may be
mimicked by spinal shock, which may
persist from a few days to a few weeks
which causes total neurologic
dysfunction distal to the site of injury.
• during which time the patient’s
prognosis cannot be accurately
assessed.
• A complete spinal cord lesion will
remain unchanged after the cessation
of spinal shock.

Incomplete Spinal Cord Lesions
• Approximately 90% of incomplete spinal
injuries can be classified as one of three
clinical syndromes:
• The central cord syndrome,
• The Brown-Sequard syndrome,
• The anterior cord syndrome

• Central Cord Syndrome
• The most common, seen in patients
with degenerative arthritis of the
cervical vertebrae when their necks are
hyperextended.
• concussion or contusion of the central
gray matter in the most central portions
of the pyramidal and spinothalamic
tracts.
• upper extremities are more severely
affected than the lower extremities.

• Central Cord Syndrome
• With more severe injuries, patients may
appear to be almost completely
quadriplegic and have only sacral
sparing.
• prognosis is variable, but more than
50% of patients become ambulatory
and regain bowel and bladder control,
as well as some hand function.

• Brown-Sequard syndrome
• hemisection of the spinal cord, usually
results from penetrating trauma but
may also be seen after lateral mass
fractures of the cervical spine.
• ipsilateral loss of position and vibration
sense as well as motor paralysis but
contralateral loss of pain and
temperature sensation distal to the level
of injury

• Brown-Sequard syndrome
• Virtually all patients maintain bowel and
bladder function and unilateral motor
strength, and most become ambulatory.

• Anterior Cord syndrome
• results from hyperflexion injuries
causing cord contusion, by the
protrusion of a bony fragment or
herniated disk into the spinal canal, or
by laceration or thrombosis of the
anterior spinal artery.
• Also after prolonged (longer than 30
minutes) cross-clamping of the aorta.

• Anterior Cord syndrome
• paralysis and hypalgesia below the
level of injury with preservation of
posterior column functions, including
position, touch, and vibratory
sensations.
• When suspecting ACS urgent
neurosurgical consultation because it
may be a result of a surgically
correctable lesion.

• Other less common lesions :
• Posteroinferior cerebellar artery
syndrome.
• Horner’s syndrome
• acute cauda equina syndrome

Computed Tomography
• The CT scan is the technique of choice for
the definitive evaluation of acute cervical
spine trauma.
• CT permits examination without moving
the patient from the supine position and is
thus preferable in terms of fracture
stabilization
• (EAST) recommend that CT from the
occiput to T1 be used as the primary
screening method in blunt cervical
trauma patients

Magnetic Resonance Imaging
• CT has a higher sensitivity than MRI to
detect fractures and dislocations at the
craniocervical junction, as well as fractures
of the posterior elements of the spine.
• MRI has the ability to directly image
nonosseous structures, including
intramedullary and extramedullary spinal
abnormalities that potentially cause
neurologic deficit.

Magnetic Resonance Imaging
• MRI can identify three separate patterns of
SCI, including
• acute cord hemorrhage,
• cord edema or contusion,
• mixed cord injury
• MRI is also viewed as the best diagnostic
imaging modality for SCIWORA
• MRI, has superior resolution and lack of
ionizing radiation.
• Has contraindication

Cervical Sprain
• Patients with musculoskeletal injuries of
the spine who have only mild to moderate
discomfort without neurologic impairment
or abnormal radiographic findings are best
managed as outpatients.
• Treatment should include analgesics and
referral for follow-up evaluation.

Minor Fractures
• Most patients with spinal fractures require
hospitalization.
• Patients with isolated cervical vertebral
body compression fractures or spinous
process fractures may be managed as
outpatients if the mechanism of injury is
not significant.
• For patients with minor wedge fractures
(<10% wedge fractures) who do not have
an associated neurologic deficit, outpatient
management may also be possible.

spinal cord inj.

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