Spinal injuries, predominantly in the thoraco-lumbar and lower cervical regions, pose serious threats to both the vertebral column and neural tissues, leading to potential neurological deficits like paraplegia and quadriplegia. These injuries can stem from various mechanisms such as falls, road traffic accidents, or direct trauma, and can be classified into stable and unstable categories based on the risk of further damage to spinal stability. Management encompasses early resuscitation, immobilization, assessment of neurological status, and a multidisciplinary approach to treatment, which may include surgical intervention and rehabilitation to preserve function and enhance recovery.

1. SPINAL
INJURIES
BY: RASHMI JAIN
8th SEMESTER, MBBS

2. INTRODUCTION
• Spinal injuries carry a double threat: damage to
the vertebral column and damage to the neural
tissues. Thoraco-lumbar segment is the
‘commonest’ site of injury; lower cervical being
the next common.
• About 20% of all spinal injuries result in
neurological deficit in the form of ‘Paraplegia’ in
thoraco-lumbar or ‘Quadriplegia’ in cervical
spinal injuries.
• Commonest mode of spinal injury in –
– Developing country- fall from height
– Developed country- road traffic accident

3. ANATOMY
The vertebral
column consists
of 33 vertebrae
(7 cervical, 12
Dorsal, 5 lumbar,
5 sacral and 4
coccygeal)
joined together
by ligaments and
muscles.

4. structure
articulation

5. PATHOPHYSIOLOGY OF SPINE
INJURIES
• Stable injury is one in which the vertebral
column will not be displaced by normal
movements; in a stable injury , if the neural
elements are undamaged there is little risk of
them becoming damage.
• Unstable injury is one in which there is
significant risk of displacement and
consequent damage –or further damage – to
the neural tissues.

6. • Spinal stability assessment- Three structural
elements consideration (Denis’ classification, 1983)-
particularly useful in assessing the stability of lumbar
spine injuries.
• ANTERIOR COLUMN- ant. Half of vertebral body, ant. Part of intervertebral disc and
ant. Longitudinal ligament
• MIDDLE COLUMN- post. Half of vertebral body, post. part of intervertebral disc and
post. Longitudinal ligament.
• POSTERIOR COLUMN-pedicles, facet joints, posterior bony arch, interspinous and
supraspinous ligaments.
All fractures involving middle column and atleast one other column are regarded as
unstable , fortunately only 10% are unstable and less than 5% are a/w cord damage.

7. • PATHOPHYSIOLOGY:
MECHANISM
OF INJURY
• Traction injury ( resisted muscle effort may avulse transverse processes-
C7avulsion; CLAY –SHOVELLER’S FRACTURE)
• Direct injury ( penetrating injuries by firearm and knives)
• Indirect injury (most common, d/t fall from height or violent free
movements of neck or trunk; variety forces applied on spine like- axial
compression/ flexion/lateral compression/flexion-rotation/shear/flexion –
distraction and extension)
PRIMARY
CHANGES
• May be limited to vertebral column including soft tissue components.
• Spinal cord or nerve roots injured either by initial trauma or ongoing
structural instability od vertebral segment causing direct compression
,energy transfer, physical disruption or damage to blood supply.
SECONDAR
Y CHANGES
• Hours and days following spinal injury , biochemical changes may lead to more gradual
cellular disruption and initial neurological damage.

8. CLASSIFICATION
• Flexion injury
• Flexion rotation injury
• Vertical compression injury
• Extension injury
• Flexion distraction injury
• Direct injury
• Indirect injury due to violent muscle
contraction

9. FLEXION INJURY
Examples:
1. Heavy blow across the shoulder by
a heavy object;
2. Fall from height on the heels or
buttocks
Results:
1. A sprain of the ligaments and
muscles of the back of the neck
2. Compression fracture of the
vertebral body, C5 to C7
3. Dislocation of one vertebra over
another.
It is a stable injury

10. FLEXION-ROTATION INJURY
Examples:
1. Heavy blow onto one shoulder
causing the trunk to be in
flexion and rotation to the
opposite side
2. A blow or fall on postero-lateral
aspect of the head
Results:
1. Dislocation of the facet joints on
one or both sides
2. Fracture dislocation of the
cervical vertebra
While dislocating, the upper vertebra
takes a slice of the body of
lower vertebra with it.
It is highly unstable injury.

11. VERTICAL COMPRESSION INJURY
Examples:
1. A blow on the top of the
head by some object
falling on the head
2. A fall from height in erect
position
Results:
This force results in “burst
fracture” i.e. the vertebral
body is crushed
throughout its vertical
dimensions.
It is an unstable injury.

12. EXTENSION INJURY
Examples:
1. Motor vehicle accident –
the forehead striking
against the windscreen
forcing the neck into
hyperextension
2. Shallow water diving – the
head hitting the ground,
extending the neck
Results: The injury results in a
chip fracture of the
anterior rim of a vertebra.
These injuries may be
unstable.

13. FLEXION–DISTRACTION INJURY
Example:
With the sudden stopping of
car, the upper part of the
body is forced forward by
inertia, while the lower part
is tied to the seat by seat
belt.
Result:
Horizontal fracture extending
into the posterior elements
and involving a part of the
body. It is termed as
“chance fracture”.
It is an unstable injury.

14. DIRECT INJURY
Examples:
1. Bullet injury
2. A lathi blow hitting the spinous processes of
the cervical vertebrae
Results:
Any part of the vertebra may be smashed by a
bullet, but, a lathi blow generally causes a
fracture of the spinous processes only.

15. VIOLENT MUSCLE CONTRACTION
Example:
Sudden violent contraction of the psoas.
Result:
Fracture of transverse processes of multiple
lumbar vertebrae. It may be associated with
huge retro-peritoneal haematoma.

16. CLINICAL FEATURES
• Pain in the back following severe violence to
the spine.
• Neurologic deficit: Sometimes, a patient is
brought to the hospital with complaints of
inability to move the limbs and loss of
sensation. Sometimes, the paralysis may
ensure late, or may extend proximally due to
traumatic intra-spinal haemorrhage.

17. PRINCIPLES OF DIAGNOSIS AND
INITIAL MANAGEMENT

18. EARLY MANAGEMENT
• Adherence to resuscitation protocol (ATLS).
• Adequate oxygenation, ventilation and circulation
will minimize secondary spinal cord injury.
• Essential principle: if there is the slightest
possibility of a spinal injury in a trauma patient,
the spine must be immobilized until the patient
has been resuscitated and other life threatening
injuries have been identified and treated.
• Abandoning of immobilization only when spinal
injury has been excluded both by clinical and
radiological assessment.

19. • Methods of Temporary Immobilization
CERVICAL SPINE : In–line immobilization
Head and neck supported in the neutral position.
QUADRUPLE IMMOBILIZATION: Patient is on a
b backboard, head is supported by sandbags and
held with tape across forehead and semi rigid
collar applied.

20. • The patient should be moved without flexion or
rotation of the thoracolumbar spine. A scoop
stretcher and spinal board are very useful for this.
• Logrolling technique used for:
– Placing patient on spinal board.
– Examining the back of patient.
• Medical therapy:
– Early treatment with high doses of corticosteroids
( methylprednisolone, 30 mg/kg , i.v. ; followed by
maintenance dose of 5.4 mg/kg/hr for 23 hours) may
improve neurological recovery if commenced within 8
hours following the injury; albeit the evidence is limited
and some neurosurgical guidelines do not recommend
their use. [Source- CMDT-2017]

21. DIAGNOSIS

22. • HISTORY:
Crucial d/t minimal symptoms and signs.
H/o blunt injury above clavicle, a head injury
or loss of consciousness – cervical injury; until
proven otherwise.
H/o fall from height or high speed deceleration
–thoracolumbar injury; until proven
otherwise.
Hold high index of suspicion; especially lesser
injuries are followed by pain in the neck or
back or neurological symptoms in limbs.

23. • EXAMINATION:
– GENERAL EXAMINATION:
 ATLS guidelines to take precedence.
Assess whether patient is not developing either of the
following shock which are commonly encountered in
patients having spinal injury.
• Hypovolemic Shock suggested by tachycardia, peripheral
shutdown and in later stages by hypotension.
• Neurogenic Shock- suggested by combination of paralysis,
warm and well- perfused peripheral areas, bradycardia and
hypotension with a low diastolic blood pressure .
• Spinal Shock- occurs when spinal cord fails temporarily
following the injury as the injury mechanism causes the
immediate depolarization of the axonal membranes resulting
in spinal shock.
» All the reflexes are absent during the phase of spinal
shock.
» Typically lasts for 24-48 hrs after the injury.
BULBOCAVERNOUS REFLEX – reflex returning first,
marking end of spinal shock.

24. – EXAMINATION OF NECK & BACK:
Neck – inspect for deformity/bruising/ penetrating
injury. Bones and soft tissues of neck are gently
palpated for tenderness and areas of bogginess or
increased space b/t the spinous processes( suggesting
instability due to posterior column failure).
Back of the neck should also be examined thoroughly.
Throughout the examination of neck , the cervical
spine must not be moved because of the risk of
injuring the cord in c/o unstable injury.
 Back- logrolled and inspected for
deformity/penetrating injury/ hematoma/ bruising.
Bone and soft tissue structures are palpated.
Haematoma/ a gap/ a step – signs of instability.

25. – NEUROLOGICAL EXAMINATION:
Full neurological examination carried out in every case,
repeated several times during the first few days where
each dermatome, myotome and reflexes is tested.
The unconscious patient are difficult to examine . A
spinal injury must be assumed until proven otherwise.
Clues to existence of spinal cord lesion are h/o fall from
height/ high speed deceleration/ head injury, flaccid
anal sphincter , hypotension with bradycardia etc.

26. • INVESTIGATIONS:
– X-RAYS:
Mandatory for:
• all accident victims complaining of pain or stiffness in the neck or
back or peripheral paraesthesia .
• all patients with head injury or severe facial injuries( cervical
spine ).
• patients with rib fractures or severe seat-belt bruising ( thoracic
spine).
• severe pelvic or abdominal injuries (thoracolumbar spine).
Performed during secondary survey.
Should be carried out with a minimum of movements and
manipulations. No attempts should be made to obtain ‘
flexion and extension’ views during initial work up.
Features on plain x-ray-Change in general alignment of
spine /Reduction in height of vertebra/Antero-posterior or
sideways displacement of one vertebra over
another/Fracture Of vertebral body/Fracture of the posterior
elements: pedicle, lamina, transverse process

27. Radiological feature suggestive of unstable injury
• Wedging of the body with the anterior height of the vertebra reduced more
than half of the posterior height
• Fracture dislocation on x-ray
• Rotational displacement of spine
• Injury to the facet joints, pedicle, or lamina
• An increase in space between the adjacent spinous processes as seen on
lateral x-ray.

28. PITFALLS IN CASE OF CHILDREN :
1. Normal features mistaken as fracture
– Growth plates and synchondroses can be mistaken for
fracture. Normal synchondrosis at the base of the dens has
usually fused by the age of 6 yrs, but it can be mistaken for an
undisplaced fracture.
– The spinous process growth plates also resembles fractures;
and the growth plate at the tip of odontoid can be taken for a
fracture in older children.
2. Spinal cord injury despite normal radiograph
• SCIWORA- Spinal Cord Injury Without Obvious
Radiographic Abnormality; interestingly radiographs
are normal but there is neural deficit.
Occurs d/t lax ligaments permitting traction injury to
cord . Cervical spine is most commonly affected.

29. – CT –Scan:
Ideal for showing structural damage to individual
vertebrae and displacement of bone fragments into the
vertebral canal.
Screening CT employed routinely in many centres, the
drawback is its high level of radiation exposure.
CT myelography, with the intrathecal introduction of
contrast agent , provides information on the
dimensions of spinal canal , impingement fracture
fragments or intervertebral disc ,and root avulsion .
This investigation is largely replaced by MRI.
– MRI:
 Method of choice for displaying the intervertebral
discs, ligamentum flavum and neural structures .
 Indicated for all the patients with neurological signs
and those who are considered for surgery.

30. PRINCIPLES OF DEFINITIVE
TREATMENT

31. • OBJECTIVES :
– To preserve neurological function;
– To minimize a perceived threat of neurological
compression;
– To stabilize the spine;
– To rehabilitate the patient.
• Indications for urgent surgical stabilization :
– an unstable fracture with progressive neurological
deficit and MRI signs of likely further neurological
deteriorations.
– controversially an unstable fracture in a patient
with multiple injuries.

32. Approach to a patient with No Neurological Deficit
STABLE
INJURY
UNSTABL
E INJURY
• Treated by spine support in a
position to prevent further
strain; using firm collar or
lumbar brace.
• Bed rest till pain & muscle spasm
subsides.
• Correction of deformity by
surgery – controversial, should
be offered choice b/t surgery for
early mobilization and d/s or
conservative management which
is likely to take longer.
• Securing till tissue healing &
spine becomes stable.
• For cervical spine- to be done
asap by traction , using tongs or
a halo device attached to skull.
• For thoracolumbar spine- in-
ternal fixation carried out.

33. Approach to a patient with Neurological Deficit
Management by multidisciplinary team that can optimally manage
their multisystem physiological impairment & malfunction including
spinal injury.
STABLE INJURY
( RARE)
UNSTABLE INJURY
(COMMON)
• Treated conservatively.
• Rehabilitated as soon
as possible.
• Conservative Rx highly demanding; best carried out
in a special unit equipped for round the clock
nursing , 2-hrly turning routines, skin toilet, bladder
care, specialized physiotherapy and occupational
therapy.
• Early operative stabilization –preferred by many.
Adv- facilitates nursing by inexperienced carers and
reduces risk of spinal deformity.
• Medical Rx with corticosteroids within few hours of
injury to counteract secondary pathophysiological
changes a/ w cord injury.

34. TREATMENT METHODS

35. CERVICAL SPINE
FIXATION
CERVICAL
COLLAR
HALO
DEVICE
FOUR-POSTER
BRACE
TONGS TRACTION
• Soft collars- little biomechanical support; use
restricted to minor sprains for first few days
following the injury.
• Semi-rigid collars- widely used in acute setting
• Four-poster braces-more stable but
uncomfortable; apply pressure to mandible,
occiput, sternum and thoracic spine.
• Four pins inserted into the
outer table of skull and a
ring is applied .
• Can be used for initial
traction and reduction of
fracture or dislocation, can
be attached to plaster vest.
• Risk- pin loosening, pin-site
infection and respiratory
distress in elderly.
• GARDENER-WELL TONGS- pin inserted
into the outer table on each side of
skull, mounted on a pair of tongs and
traction applied to reduce the
fracture or dislocation and to
maintain the reduced position.

36. THORACOLUMBAR SPINE
BRACE

37. PROTOCOL OF DEFINITIVE
MANAGEMENT OF SPINAL INJURIES
INJURY TO SPINE
C-SPINE STABILIZATION/RESUSCITATION
PROTOCOL/ TRANSFER TO HOSPITAL
NO
NEUROLOGICAL
DEFICIT
UNCONSCIOUS CONSCIOUS
STABLE SPINE
CONSERVATIVE
(spontaneous
fusion/surgical
fusion)
Breathing pattern + reflexes ASIA scoring+ reflexes
SPINAL SHOCK
• RECOVERED –marked by return of bulbocavernous reflex
• Distal movements/sensation- +nt(incomplete lesion- may be
progressive neural worsening; skeletal disruption; bowel
bladder involvement—spinal fusion)/-nt(complete lesion—
Poor prognosis and rehabilitation)

38. COMPLICATIONS
• Pulmonary complications - Function compromise, Airway
compromise, infection, decreased vital capacity, atelectasis, retention of
secretions, respiratory failure, pulmonary edema.
• Acute respiratory failure is the leading cause of death in high cervical
injuries.
• GI & GU Dysfunction -Assess for bowel distention, ileus or
gastrointestinal bleeding - may require an NGT. During acute injury
phase, the bladder is atonic so the patient is unable to void voluntarily
or spontaneously - also increases risk of UTI. Maintain strict Intake and
Output .Begin bladder training.
• Orthostatic hypotension- venous pooling in the legs and abdomen,
loss the skeletal muscle pump, and impaired sympathetic nervous
system control of BP. It can result in syncope, bradycardia, or asystole.
Treated by quickly returning the patient to a supine position,
administering oxygen, and if necessary, atropine to increase heart rate.
• DVT is extremely high in SCI patients d/t pressure on their calf muscles,
loss of the skeletal muscle pump, and the hypercoagulability of their
blood. Treatment :DVT prophylaxis - pneumatic compression hose, low
dose Heparin, and vena cava filters.
• Skin -Below the level of SCI, the patient cannot sense discomfort from pressure,
skin irritants, or temperature extremes. Patient will remain at high risk for pressure
ulcers, serious skin injury and infection. Special beds to be used to prevent bed
sores.

39. REHABILITATION
• Mobility - initially may require a brace or halo. Needs to bear weight as
soon as possible because it helps decrease disuse atrophy, decrease the
opportunity for osteoporosis and enhances metabolic processes.
• Exercise - to strengthen unaffected parts and promote self-care.
• Urinary and Bowel training - learn how and when to self-catheterize,
check for retained urine, able to recognize impaction and ileus etc.
• May require long term use of anti spasmodic drugs like baclofen. Spastic
activity may be there for 2 years or so and then minimize thereafter.
• Self-Esteem - May need counseling to deal with changes in self-identity,
sexual function, social and emotional roles. Needs to feel strong, lovable
and loved.
• Psychosocial behaviour- Denial, anger and depression are common
reactions to SCI. The SCI patient will ask the question of walking again.
Often this question cannot be answered in the immediate post-injury
phase. The goals are to provide honest and realistic communication about
the nature of the injury and help the patient develop short-term goals.