Spinal Cord Injury Lecture Presentation for Medical Students.

SPINAL CORD INJURY
Presenter: Dr KESHENI LEMI
SUPERVISOR :ATYAM SOLOMON ,ORTHOPEDIC SURGEON

OUTLINE
 Clinical anatomy
 Epidemiology
 Risk factorsCauses
 Mechanism of injury Pathophysiology
 Classifications
 Common Fractures
 Clinical Features
 Investigations
 Management
 Complications

External features of spinal cord
 Definition : it is the lower part of the central
nervous system
 Shape : irregular cylindrical mass
 Site : it lies within the vertebral canal (boney
canal)
 Length : average 45cm in length and 1.5 cm in
diameter, in adults being 25cm less than the
length of the vertebral column
 Extension : from slightly below the foramen
magnum superiorly, to the level of the lower
border of the 1st
lumbar vertebra or the upper
border of the 2nd
lumbar vertebra or in between
(in adults)

Age variations in the length of spinal cord
 At the 3rd
month of pregnancy : it occupies
the full length of the vertebral canal
 At full term (end) of pregnancy : it reaches
the level of the 3rd
lumbar vertebra
 In adults : it reaches the level of the lower
border of the 1st
lumbar vertebra

End of the spinal cord
 The spinal cord ends as a
conical mass called
(conus medullaris)
 At this site the lumbar,
sacral, and coccygeal
nerves are collected in a
manner like the tail of
the hoarse called (cauda
equina)

Enlargements of the spinal cord
 The spinal cord along its course is not a
complete cylindrical mass but it has two
enlargements
1. Cervical enlargement : lying at the level
of the lower cervical vertebrae
representing the orgin of brachial plexus
2. Lumbar enlargement : lying at the level of
the lower vertebrae representing the origin
of lumbar plexus

Coverings of the spinal cord
 The spinal cord is covered with 3
membranous envelops called meninges
arranged from superficial to deep as
follows :
1. Outer covering called dura matter
(fibrous membrane)
2. Intermediate covering called arachnoid
matter (transparent membrane)
3. Inner covering called pia matter
(vascular membrane)

Components of spinal nerves
 Each spinal nerves arises from the
spinal cord by 2 roots
1. Ventral (motor) root
2. Dorsal (sensory) root
 The 2 roots unite at the intervertebral
foramen to form a (Mixed trunk)
 The mixed trunk (spinal nerve) divide
into :
A. Ventral ramus (mixed)
B. Dorsal ramus (mixed)

Fixation of the spinal cord
 The spinal cord is supported and fixed in a central
position within the vertebral canal by 3
derivatives from its covering as follows :
1. Filum terminale (fix the spinal cord inferiorly
to the back of coccyx)
2. Ligamenta denticulate (fix the spinal cord
laterally with the dura mater)
3. Dura mater (fix the spinal cord above with
the foramen magnum and below with the
intervertebral foramina)

Segments of spinal cord
 The spinal cord is divided into 31
segments
 8 cervical
 12 thoracic
 5 lumber
 5 sacral
 1 coccygeal
 Note 1 (from each segment one pair of
spinal nerves arises)
 Note 2 (spinal segments are not
corresponding to vertebral column)

The three column concept of spinal stability
 The spinal column can be divided into three columns:
anterior, middle and posterior .When all three
columns are injured the spine is unstable.

Epidemiology of Spinal Cord Injury.
 The incidence and causation of spinal cord injury vary globally
and reflect the demographics and industrialisation of society.
 Every year, around the world, between 250 000 and 500 000
people suffer a spinal cord injury according to the World Health
Organization in 2013.
 Road traffic accidents 44% remain the leading cause of spinal
cord injuries worldwide.
 Total spinal cord injury contributes to current burden of traumatic
spinal injuries in africa 13.6 new cases per 100,000 persons.
 the incidence of TSCI varied from 13 per million in Botswana to
75.6 per million population in south Africa
 Men in the third decade of life are the most likely group to
sustain serious spinal cord injury.

Traumatic spinal cord injury in Uganda
 The epidemiology of TSCI in developing countries is
recognized to include transport related injuries,
falls, industrial accidents and violence, including
gunshot wounds.1–5 In Uganda, transport injuries
typically involve head-on and roll-over crashes due
to excessive speed, lax securing of unstable loads,
very limited use of protective helmets and
vulnerability of pedestrians to being struck when
crossing busy or unlit roads.

Pathophysiology of spinal cord injury
 The primary injury
This is the direct insult to the neural elements and occurs at the
time of the initial injury.
 The secondary injury
Haemorrhage, oedema and ischaemia results in a biochemical
cascade that causes the secondary injury.
1. hypotension,
2. hypoxia,
3. spinal instability and/or
4. persistent compression of the neural elements. Management of
5. a spinal cord injury must focus on minimising secondary injury.

CLASSIFICATION
CLASSIFICATION
Spinal injuries are best classified on the basis of mechanism of
injury into the following types:
• Flexion injury
• Flexion-rotation injury
• Vertical compression injury
• Extension injury
• Flexion-distraction injury
• Direct injury
• Indirect injury due to violent muscle contraction

SPECIFIC SPINAL INJURIES
1: Upper cervical spine (skull–C2)
Craniocervical dislocation
This injury is usually caused by high energy trauma and is often fatal.
The dislocation may be anterior, posterior or vertical Power’s ratio is
used to assess skull translation.
Atlantoaxial instability
This is uncommon and either resolves spontaneously or with traction.
Isolated, traumatic transverse ligament rupture leading to C1/2
instability is uncommon and is treated with posterior C1/2 fusion.
Occipital condyle fracture
This is a stable injury often associated with head injuries, and is best
treated in a hard collar for 8 weeks

Jefferson fractures (C1 ring)
These injuries are associated with axial loading of the
cervical spine and may be stable or unstable.
Associated transverse ligament rupture may occur .
Most are treated non-operatively in a collar or halo
brace.

Odontoid fractures
There are three types of
Odontoid peg fracture
Neurological injury is rare. The
majority of acute injuries are
treated non-operatively in a
halo jacket or hard collar for
three months. Internal fixation
with an anterior compression
screw is indicated. in
displaced fractures Posterior
C1/2 fusion is required in
cases of non-union.

Hangman’s fracture
The Hangman’s fracture is a
traumatic spondylolisthesis of
C2 on C3. There are four
types with varying degrees
of instability . Those with
significant displacement or
associated facet dislocation
are treated operatively,
usually with posterior
stabilisation .

2: Subaxial cervical spine (C3–C7)
The pattern of lower cervical spine injury depends on the
mechanism of trauma.
 These include wedge (hyperflexion),
 burst (axial compression),
 tear-drop fractures (hyperextension)
 and facet subluxation/dislocation (rotation and hyperflexion).
The more severe injuries are accompanied by spinal cord injury.
Operative intervention may be required to decompress the spinal
cord and stabilize the spine with internal fixation.
Facet subluxation/dislocation ranges in severity from minor
instability to complete dislocation with spinal cord injury.

Thoracolumbar
The thoracic spine is stabilized significantly by the rib
cage. The lumbar spine has comparatively large
vertebrae. Thus, the thoracolumbar spine has a higher
threshold for injury than the cervical spine

AO CLASSIFICATION
The system developed by the AO (Arbeitsgemeinschaft
fu˝r Osteosynthesefragen) can be used to classify these
fractures. There are three main injury types (A, B and C)
with increasing instability and risk of neurological injury.
Type A fractures involve the vertebral body.
Type B injuries have additional distraction/ disruption of
the posterior elements and
Type C injuries are rotationaL.
The majority of type B and type C injuries requiresurgical
stabilization.

Thoracic spine (T1–T10)
Osteoporotic wedge compression fractures in the
elderly are the most common injury in this group.
Symptomatic fractures can be treated with
percutaneous bone cement augmentation, known as
vertebroplasty or kyphoplasty.
In trauma cases, unstable fractures are associated
with significant energy transfer to the patient and
may be associated with major internal injuries, such as
pulmonary contusion and spinal cord injury.

Thoracolumbar spinal fractures (T11–S1)
The thoracolumbar junction is especially prone to injury. This
can vary from a minor wedge fracture to spinal dislocation.
Burst fractures are comminuted fractures of the vertebral
body. Usually the distance between the pedicles is widened
and bone fragments are retropulsed into the spinal Canal .
The surgical approach can be anterior, posterior or
combined. For burst fractures with neurological compromise,
an anterior approach with vertebral corpectomy, canal
clearance and anterior reconstruction is often used.

Fracture patterns
Compression Fracture
Compression fracture is a compression/ flexion injury causing
failure of the anterior column only. It is stable and not
associated with neurologic deficit, although the patient may still
have significant pain.
Burst Fracture
Burst fracture is a pure axial compression injury causing failure
of the anterior and middle columns. It is unstable, and perhaps
half of patients have neurologic deficit due to compression of
the cord or cauda equina from bone fragments retropulsed into
the spinal canal.

Fracture patterns
Chance Fracture
Chance fracture is a flexion-distraction injury causing failure of the
middle and posterior columns, sometimes with anterior wedging.
Typical injury is from a lap seat-belt hyperflexion with associated
abdominal injury. It often is unstable and associated with neurologic
deficit.
Fracture-Dislocation
Fracture-dislocation is failure of the anterior, middle, and posterior
columns caused by flexion/distraction, shear, or compression forces.
Neurologic deficit can result from retropulsion of middle column
bone fragments into the spinal canal, or from subluxation causing
decreased canal diameter.

Clinical presentation of spine injuries
 Loss of movement (paresis/weakness, plegia/paralysis).
 Loss of sensation (hypoesthesia or numbness)
 Loss of bowel and/or bladder control (incontinence).
 Exaggerated reflex actions or spasms e.g.
hyperreflexia.
 Changes in sexual function, sexual sensitivity and
fertility.
 Pain or intense stinging sensation e.g. parathesias

PATIENT ASSESSMENT
Basic points
Advanced Trauma Life Support (ATLS) principles apply in all Cases .
The spine should initially be immobilised on the assumption that every
trauma patient has a spinal injury until proven otherwise . The finding
of a spinal injury makes it more likely (not less) that there will be a
second injury at another level.
The unconscious patient
Definitive clearance of the spine may not be possible in the initial
stages and spinal immobilisation should then be maintained, until
magnetic resonance imaging (MRI) or equivalent can be used to rule
out an unstable spinal injury

PERTINENT HISTORY
PERTINENT HISTORY
The mechanism and velocity of injury should be
determined at an early stage. A check for the
presence of spinal pain should be made.
The onset and duration of neurological symptoms
should also be recorded.

PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
Initial assessment The primary survey always takes
precedence, followed by careful systems examination,
paying particular attention to the abdomen and chest.
Spinal cord injury may mask signs of intra-abdominal
injury.

Identification of shock
Three categories of shock may occur in spinal trauma:
1 Hypovolaemic shock. Hypotension with tachycardia and cold clammy
peripheries. This is most often due to haemorrhage. It should be treated
with appropriate resuscitation.
2 Neurogenic shock. This presents with hypotension, a normal heart rate
or bradycardia and warm peripheries. This is due to unopposed vagal
tone resulting from cervical spinal cord injury above the level of
sympathetic outflow (C7/T1). It should be treated with inotropic support,
and care should be taken to avoid fluid overload.
3 Spinal shock. There is initial loss of all neurological function below the
level of the injury. It is characterised by paralysis, hypotonia and
areflexia. It usually lasts 24 hours following spinal cord injury. Once it has
resolved the bulbocavernosus reflex returns.

Neurological examination
Neurological examination
Level of neurological impairment
The ASIA neurological impairment scale is based on the
Frankel classification of spinal cord injury:
• A, complete;
• B, sensation present motor absent;
• C, sensation present, motor present but not useful (MRC
grade <3/5);
• D, sensation present, motor useful (MRC grade ≥3/5);
• E, normal function.

Motor scoring system
GRADE D5ESCRIPTION
0 No muscle contraction
1 Visible muscle contraction without movement
across the joint
2 Movement in the horizontal plane, unable to
overcome gravity
3 Movement against gravity
4 Movement against some resistance
5 Normal strength

DIAGNOSTIC IMAGING
 X-ray
 Ct scan
 MRI
 E fast Us
 Basic investigations
Indications for C-spine Films:
1. Tenderness
2. Neurologic defecit
3. Forceful Mechanism of injury
4. Distracting injury
5. Altered sensorium

Interpretation of Lateral Plain Film
 Mnemonic AABCS
 Adequacy
 Alignment
 Bones
 Cartilage
 Soft Tissue

Interpreting Lateral Plain Film
 Adequacy
 Should see C7-T1
junction
 If not get swimmer’s
view or CT

Interpreting lateral Plain Film
 Alignment
 Anterior vertebral line
 Formed by anterior borders of vertebral bodies
 Posterior vertebral line
 Formed by posterior borders of vertebral bodies
 Spino-laminar Line
 Formed by the junction of the spinous processes and the laminae
 Posterior Spinous Line
 Formed by posterior aspect of the spinous processes

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)
 Extremely variable and
nonspecific

TREATMENT
The treatment of spinal injuries can be divided into
three phases, as in other injuries:
Phase I Emergency care at the scene of accident or in
emergency department.
Phase II Definitive care in emergency department, or
in the ward.
Phase III Rehabilitation.

Emergency treatment
 ABCDE
 Keep warm
 Treat if BP<80mmHg & HR <50bpm
 Gardener wells calipers for traction
 H2 Antagonists & Heparin
 Methylprednisolone 30mg/kg iv bolus over 15min
immediately can use dexamethazone instead
 45minutes after the bolus a 5.4mg/kg/h infusion over
23 hrs in first 3 hours after the injury.
 5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.

Care in A&E
 Careful manual handling especially if unconscious
 Jaw thrust is safer
 Correct gross spinal deformities
 Call the anesthetist if diaphragmatic paralysis or RR>35
 Use flexible fibreoptic scopes in unstable fractures
 Ryles tube if abdominal distension causes respiratory
problems.
 Cathetrize to avoid overstretching of detrusor muscle
 IV fluids – paralytic ileus in first 48hrs.
 Passive movements to rule out fractures
 Small iv doses of opiates

Definitive Management & Rehabilitation
 Spinal-Dose Steroids- Methylprednisolone
 Orthotic Devices e.g. Philadelphia and Miami-J
collars, Cervical collars are inadequate for C1, C2,
or cervicothoracic instability, thoracolumbosacral
orthoses etc.
 Surgery- for decompression of the spinal cord and
nerve roots, and stabilization of the spine.
 Continued Care.

Complications of spinal injury
Organ System Complications
Cardiovascular Bradycardia/ dysrhythmia, Cardiac arrest
Cardiogenic pulmonary edema
Pulmonary Hypoventilation/respiratory failure, Poor secretion control
Acute respiratory distress syndrome, Aspiration, Pneumonia
Gastrointestinal Gastric dysmotility, Adynamic ileus, Gastritis and ulceration,
Pancreatitis
Hematologic Venothromboembolism
Neurologic Neurogenic shock, Depression, Posttraumatic stress disorder
Anxiety, Autonomic dysreflexia
Genitourinary Bladder dysfunction, Urinary tract infection, Priapism
Integument Pressure ulceration

References
 Schwartz’s Principles of Surgery Eleventh Edition
 SABISTON TEXTBOOK of SURGERY The BIOLOGICAL BASIS of MODERN SURGICAL PRACTICE 21
Edition.
 Bailey & Love’s SHORT PRACTICE of SURGERY 28 Edition.
 SRB's Manual of surgery Sri ram Bhat M MS (General Surgery) Professor and Head Department of
Surgery Kastu rba Medical College Mangalore Mangaluru, Karnataka, India Honorary Surgeon
Government Wenlock District Hospital Mangaluru, Dakshina Kannada, Karnataka, Indiae-ma ii:
meera_sriram2003@yahoo.com 6thedit.
 Kenneth L. Mattox, MD David V. Feliciano, MD, Ernest E. Moore, MD, TRAUMA, 8th
edition,2017
 Advanced Trauma Life Support (ATLS) 10th edition, 2018
 Burden of traumatic spinalcord injury in sub saharan africa. A SCOPIING REVIEW , article by
Damilola jesuyajolu publishe November 2023.
 SPINAL CORD INJURY ppt presentation by Mamta Toppo and N.kumari shared aguast 2020.
 Traumatic spinal cord injury in Uganda: a prevention stratergy and mechanism to improve home care
journal article by L STOTHERS published August 2017.
 internet

Spinal Cord Injury Lecture Presentation for Medical Students.

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Spinal Cord Injury Lecture Presentation for Medical Students.