2. Epidemiology
Incidence 2-5/100,000
about 10% will result in quadriplegia or paraplegia .
50% affects the cervical region
Adolescent and young adults males are the most
affected.
Most are a consequence of road traffic accidents
3. Mechanisms of injuries
Vertebral body fracture
Disc herniation
Displacement of post. wall of thee vertebral
body
Tearing of interspinous ligaments .
Disruption of post. Ligament .
Tearing of Ant. Long. Lig.
Separation of vertebral bodies .
Avulsion of upper vertebral body from
disc.
Associated with unilateral facet dislocation .
10. The Three- Column Theory
When describing and diagnosing spinal fractures , spine surgeons divide the
spinal column into 3 sections :
Ant. Column >> ant. Long. Ligament + ant. One half of the vertebral body, disc,
annulus.
Middle column >> Post. Long. Lig. + post. Half of the vertebral body, disc,
annulus.
Post. Column >> facet joints, ligamentum flavum , post elements and the
interconnecting lig.
Types of
Fractures Seat belt
fractures
Wedge
fracture
Burst
dislocation
11.
12.
13. Stable and Unstable Fractures :
Generally , a fracture is considered Stable if only the ant. Column is involved, as in
most of wedged fractures.
Wheen the ant. And middle columns are involved the fracture may be considered
more unstable.
When all three columns are involved the fracture is considered by definition Unstable.
Types of Fracture Column Affected Stable Vs. Unstable
Wedge fracture Ant. Only STABLE
Burst fracture Ant. And Middle UNSTABLE
Fracture /
dislocation injuries
Ant.
Middle
Post.
UNSTABLE
Seat belt fractures Ant.
Middle
Post.
UNSTABLE
15. Whiplash Injury ..
Traumatic injury to the soft tissue structures in the region of the cervical spine
(including ligaments, muscles , intervertebal discs…. ) due to hyperflexion
hyperextension or rotational injury to the neck in he absence of fractures ,
dislocations.
Clinical grading of WAD severity
Grade Description
0 No complaints , no signs
1 Neck pain or stiffness or tenderness , no signs
2 Above symptoms with reduced range of motion
or point of tenderness.
3 Above symptoms with weakness , sensory
deficit , or absent deep tendon reflexes .
4 Above symptoms with fracture or dislocation.
WIPLASH
Grade 1 : Pts with NL
mental status and physical
exam don’t require plain
radiographs on
presntation
Grade 2,3 : C- spine x rays
, special imaging aren’t
indicated.
Grade 3,4 : Should be
managed a suspected
spinal cord injury .
16. Recommendation Grade 1 Grade 2 Grade 3
Range of motion exercises Should be started immediately for all
Encourage early return to regular
activities
immed ASAP
Cervical collars and rest No not> 72 hrs in not> 96 hrs
Passive modality therapies :
heat,ice,massage,TENS,
ultrasound,acupuncture
No Optional if symptoms last > 3 wks
Medication : optional use of NSIADS and
non narcotic analgesics
No Yes Yes . Limited narcotics
are needed
occasionally
Surgery No No Only for progressive
neurological deficit or
persisting arm pain
Not recommended : cervical pillows and soft collars , bed rest , spray and stretch
exercises , muscle relaxant med. ,intra-articular intrathecal or trigger point steriod
injection
17. Completeness of lesion ..
Incomplete lesions : any residual motor or sensory fxn more than 3
segments below the level of injury.
- Sacral sparing ; sensation around the anus, voluntary rectal
sphincter contraction , or voluntary toe flexion
- an injury does not qualify as incomplete with preserved
sacral reflexes alone .
Complete lesion : NO preservation of any motor and/or sensory fxn more
than 3 segments below the level of the injury. ( the persistence of a
complete spinal cord injury beyond 24 hrs indicates that no distal fxn will
recover . Only 3% will recover within 24 hrs . )
18. Spinal Shock ….
** Transient loss of all neurological function ( including segmental and
polysynaptic reflex activity and autonomic fxn) below the level of SCI >
flaccid paralysis and areflexia lasting varying periods ( as minimal of 3-4
days or up to 6-8 wks or sometimes permanently ) , the resolution of
which yields thee anticipated spasticity below the level of the lesion .
21. Ant. Spinal cord syndrome
Compression of the ant. Aspect of cord > leads to the damage
of corticospinal an spinothalamic tracts > motor paralysis
below level + loss of pain an temp. and touch but with
preservation of light touch , propriocption and position
sensation.
Central spinal cord syndrome
Usually due to hyperextension of cervical spine . The damage
is located centrally with the most severe injury to the
more centrally lying cervical tracts which supplying Uls.
Disproportionately greater weakness in UL in
comparison with the LL below the level of injury .
22. Brown – Sequard syndrome
Hemidisection of spinal cord .
Ipsilateral paralysis below the level
Loss of pain and temp. and touch contralaterally
Loss of position sence , proprioception ipsilaterally
25. The most severe consequence of spinal trauma is complete transverse myelopathy in
which all neurological function is absent below the level of the lesion, causing
either paraplegia or quadriplegia, depending on the level.
There will also be impairment of autonomic function including bladder and bowel.
MOTOR DEFICIT
Injuries to the spinal cord will cause upper motor neuron
paralysis characterized by loss of voluntary function
Increased muscle tone and hyperreflexia.
Injuries to the lumbar spine causing cauda equina
injuries result in lower motor neuron paralysis
characterized by reduced muscle tone, wasting
and loss of reflexes.
Combination of upper and lower motor neurone lesions
result from a thoracolumbar injury involving the
conus medullaris and cauda equina.
26. SENSORY DEFICIT
In complete lesions the afferent long tracts carrying the various sensory modalities are
interrupted at the level of the lesion, abolishing sensory appreciation of pain,
temperature, touch, position and tactile discrimination below the lesion .
Occasionally there is a level of abnormally increased sensation, hyperaesthesia and
hyperalgesia at or just below the lesion (sensory level).
AUTONOMIC DEFICIT
Vasomotor control: cervical and high thoracic lesions above the sympathetic outflow at
T5 may cause hypotension. Interruption of the sympathetic splanchnic vasomotor
control will initially cause a severe postural. hypotension as a result of impaired
venous return.
Temp. control : the patient with complete spinal lesion will not have satisfactory
thermal regulation as there will be impairment of the autonomic mechanisms for
vasoconstriction and vasodilatation .
SPLANCHNIC DISTURBANCES
Impairment in bladder and bowel control
27. Management
Aims of Management :
- Prevention of further injury to spinal cord .
- Reduction and stabilization of bony injuries .
- Prevention of complications .
- Rehabilitation .
29. Caution in turning and lifting the patient. Spine flexion should be avoided . A
temporary collar should be applied if the injury is to cervical spine.
Hypotension and hypoventilation immediately following an acute traumatic SC
injury may not be life threatening but may increase the extent of
neurological impariment. Respiratory insufficiency may require oxygen
therapy and ventilatory assistance.
Loss of sympathetic tone may result in peripheral vasodilatation with
peripheral vascular pooling and hypotension. Treatment: intravascular
volume expanders, alpha adrenergic stimulators, IV atropine, and
occasionally the use of a transvenous pacemaker.
Spinal patients are poikilothermic and will tend to assume the temperature of
the environment. Body temperature must be preserved in cold weather and
the patient must not be overheated in warm weather.
NG tube to avoid problems associated with vomiting due to gastric stasis and
paralytic ileus.
Urinary catheter, although intermittent catheterization may become
preferable later
Prophylaxis for DVT with low dose heparin or LMWH, or stockings on the lower
limbs
31. 1 - Progression of neurological deficit
2 - Patients with partial neurological injury, who fail to improve should have
further radiological assessment. Surgery should be considered if this
shows persisting extrinsic compression of the spinal cord within the
canal (particularly from herniated cervical disc), a depressed fractured
lamina or an osteophytic bar, although removal of the compression may
not result in any neurological improvement .
3 – An open injury from a gunshot or stab wound should be explored to
remove foreign particles , elevate bone spicules and if possible repair he
dura .
4 – Most common indication is to stabilize the spine
Indications for surgical interventions :
