10. Mechanism of injury
• MODES OF INJURY
Developing countries : fall from height ( most
common)
eg : fall from a tree
Developed countries : road traffic accidents ( most
common)
other modes : fall of heavy object on back
sports injuries
extreme twisting of Middle of body
Stab wound
11. STABLE AND UNSTABLE INJURY
• STABLE INJURY :
. No further displacemnent between two
vertebral bodies Because of intact mechanical linkages
• UNSTABLE INJURY :
further displacement occurs because of
serious disruption of structures responsible for
stability
12. Three column concept
from viewpoint of stability,
the spine can be divided
into three columns:
anterior, middle and
posterior
13. • The anterior column : consists of the anterior
longitudinal ligament and the anterior part of
annulus fibrosus along with the anterior half of the
vertebral body
• . The middle column : consists of the posterior
longitudinal ligament and the posterior part of the
annulus fibrosus along with the posterior half of the
vertebral body.
• The posterior column consists of the posterior bony
arches along with the posterior ligament complex.
14. • The integrity of one or more of these columns may be
disrupted, resulting in threat to the stability of the
spine.
• only one column is disrupted (e.g., a wedge
compression fracture of the vertebra) the spine is
stable.
• two columns are disrupted (e.g., a burst fracture of
the body of the vertebra) the spine is considered
unstable.
• all the three columns are disrupted, the spine is
always unstable (e.g., dislocation of one vertebrae
over other
15. Classification ( on the basis of
mechanism)
• Flexion injury
• Flexion-rotation injury
• Vertical compression injury
• Extension injury
• Flexion-distraction injury
• Direct injury
• Indirect injury due to violent muscle contraction
16. Flexion injury
Most common
Examples: (i) heavy blow across the
shoulder by a heavy object; (ii) fall
from height on the heels
result in cervical spine : (i) a sprain of
the ligaments and muscles of the back
of neck
(ii) compression fracture of
the vertebral body, C5 to C7
(iii) Dislocation of one
vertebra over another
In dorsal lumbar spine: wedge
compression of vertebrae
17. FLEXION-ROTATION INJURY
worst type ;; leaves a highly unstable
spine, associated with a high incidence of
neurological damage.
Examples: (i) heavy blow onto one shoulder
causing the trunk to be in flexion and
rotation to the opposite side
(ii) a blow or fall on postero-
lateral aspect of the head.
Results: in cervical spine :i) dislocation of
the facet joints on one or both sides
ii) fracture-dislocation of the
cervical vertebrae
In dorsal lumbar spine: fracture Dislocation
• Highly unstable
19. EXTENSION INJURY
Commonly seen in cervical spine
Examples: (i) motor vehicle
accident – the forehead striking
against the windscreen forcing
the neck into hyperextension; (ii)
shallow water diving –the head
hitting the ground, extending the
neck
Results: This injury results in a
chip fracture of the anterior rim
of a vertebra. Sometimes, may be
unstable.
21. DIRECT INJURY
Rare type
Examples: (i) bullet injury;
(ii) 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.
22. VIOLENT MUSCLE CONTRACTION
rare injury.
• Example: Sudden violent contraction of the psoas.
• Results: It results in fractures of the transverse
processes of multiple lumbar vertebrae. It may be
associated with a huge retro-peritoneal haematoma.
23. CLINICAL FEATURES
Presenting complaints-
1. Pain in back- following a severe violence to the spine.
A mild compression fracture of a vertebrae may occur from
a little jerk in osteoporotic spine of elderly person.
2. Neurological deficit- brought with complaint of inability to
move limbs and loss of sensation.
mostly there is history of violence to spine immediately
preceding onset of these complaints.
paralysis may ensue late or may extend proximally due to
traumatic intraspinal haemorrhage.
24. Patient with spinal injury should be treated as if certain unless
proven otherwise.
Utmost care is needed during examination
EXAMINATION
1. General Examination- to evaluate any hypovolaemic shock
and associated injuries to head, chest or abdomen.
2. Neurological examination- done before examining spine
per se.
Done to find expected segment of vertebral damage.
Level of motor paralysis, loss of sensation and absence of
reflexes guide about neurological level of injury.
Calculate expected vertebral level from neurological level.
25.
26. 3. Examination of spine- if not done with care in an unstable
spine, movement at fracture site may cause damage to
spinal cord.
Patient should be tilted by an assistance just enough to
permit surgeon’s hand to be introduced under injured
segment.
may feel prominence of one or more of spinous processes,
tenderness, crepitus or haematoma at site of injury.
27. INVESTIGATIONS
Plain X-rays- good antero-posterior and lateral x-rays centering
on the involved segment.
Helpful in : confirmation of diagnosis
assessment of mechanism of injury
assessment of stability of spine
Features noted-
•Change in general alignment of spine i.e. antero-posterior
bending (kyphosis) or sideways bending (scoliosis)
•Reduction in height of vertebra
•Antero-posterior or sideways displacement of one vetebrae over
another.
•Fracture of vertebral body
•Fracture of posterior elements, i.e. pedicle, lamina, transverse
process, etc
29. Occasionally plain x-ray may appear normal in highly unstable
spinal injury.
Commonly seen in whiplash injury to cervical spine where all
three columns of spine are disrupted in sudden hyperflexion
followed by sudden hyperextension of neck. Eg after sudden
stoppage of car.
Features suggestive of unstable injury:
•Wedging of body with anterior height of vertebrae reduced
more than half of posterior height.
•A fracture dislocation on X-ray
•Rotational displacement of spine
•Injury to facet joints, pedicle or lamina
•An increase in the space between adjacent spinous processes
as seen on lateral X-ray
30. MRI: best modality of imaging an injured spine.
Show better details of injured soft tissues and bones and
anatomy of cord.
CT scan: done where MRI not available
can see any bony fragment in canal.
33. • Divided into three phases –
I. PHASE 1: Emergency care at the
scene of accident or in emergency
department.
II. PHASE 2: Definitive care in
emergency department, or in the
ward.
III. PHASE 3: Rehabilitation
34. PHASE 1: EMERGENCY CARE
•At the site of accident: basic principle being
to avoid any movement at the injured segment.
While moving a person with a suspected
cervical spine injury, one person should hold the
neck in traction by keeping the head pulled. The
rest of the body is supported at the shoulder,
pelvis and legs by three other people. Whenever
required, the whole is to be moved in a one
piece so that no movement occurs at the spine.
The same precaution is observed in a case with
suspected dorso-lumbar injury.
•In the emergency department: the patient
should not be moved from the trolley on which
he is first received until stability of the spine is
confirmed. In cases with cervical spine injury,
35. A quick general examination of the patient is carried
out in order to detect any other associated injuries to
the chest, abdomen, pelvis, limbs, etc.
A thorough neurological examination of the limbs is
performed. The spine is examined for any
tenderness, crepitus, haematoma, etc. X-ray
examination, as desired, is requisitioned.
Medical management of spinal cord injury: If
the patient presents within 8 hours of injury, IV
methylprednisolone is administered followed by
maintenance dose.
Naloxone, thyrotropin-releasing hormone and GMI
gangliosides have been used.
36. PHASE 2: DEFINITIVE CARE
The aim of treatment is: (i) to avoid any deterioration
of the neurological status; (ii) to achieve stability of
the spine by conservative or operative methods; and
(iii) to rehabilitate the paralysed patient to the best
possible extent.
Treatment of cervical spine injuries:
Aim is to achieve proper alignment of vertebrae, and
maintain it in that position till the vertebral column
stabilises.
Operative stabilisation of the fractured spine has
become the treatment of choice, as it enhances the
rehabilitation.
