this power point is for educational purposes in the field of neurosurgery and spine surgery hopping to be useful for you all

2.  Spinal injury may be defined as injury to the spinal
column (bone column)/spinal cord or both
 Improper management can have horrible and permanent
result
 Appropriate use of immobilization can mean difference
between a patient who fully recovers and other spent
whole life paralyzed.

4.  Most common cervical region(55%)
 Mortality rate 40-50%
 Between the ages 16-30. M:F=4:1
 Most frequent age is 19
 Current estimates are 250,000 - 400,000 individuals living
with Spinal Cord Injury or Spinal Dysfunction
 60% of all spine injuries in children; upper cervical
spine.
 C5-C6 is the most commonly injured level in adults.

5. Ranges of Motion (in degrees)

6. 33 separate irregular bones

7. Small vetrebral body Extensive joint surface

8. Designed to remain stiff and straight

9. Weight bearing vertebrae

14. Flexion injury

15. Extension injury

17. • ant. Long. Ligament + ant. One half
of the vertebral body, disc, annulus.
Ant.
column
• Post. Long. Lig. + post. Half of the
vertebral body, disc, annulus.
Middle
column
• facet joints, ligamentum flavum , post
elements and the interconnecting
lig.
Post.
column

20. Types of
Fractures Seat belt
fractures
Wedge
fracture
Burst
dislocation

21. 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

22.  Cutting compression or stretching of spinal cord
 Causing loss of distal function sensation or motion
 Caused by:
 -unstable or sharp bony fragment pushing
the cord
 - Pressure from bone fragments or swelling that
interrupts the blood supply to the cord causing
ischemia

23.  ▪Primary spinal cord injury
- cutting, compression or stretching of spinal cord
 ▪Secondary spinal cord injury
-occurs later due to swelling, ischemia or movement
of unstable bony fragments

24. 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 . )

25.  High speed crash
 Compression injury (diving, fall on buttock)
 Significant blunt trauma
 Very violent mechanism
 Unconscious
 Neurological deficit
 Spinal pain/tenderness

26. Aims of Management :
 Prevention of further injury to spinal cord .
 Reduction and stabilization of bony injuries .
 Prevention of complications .
 Rehabilitation .

27.  Protect spine at all times during the management of patients
with multiple injuries
 Up to 5% of spinal injuries have a second (possibly non
adjacent) fracture elsewhere in the spine
 Ideally, whole spine should be immobilized in neutral position
on a firm surface
 Cervical spine immobilization
 Transportation of spinal cord-injured patients

29. Initial evaluation and treatment
 ABC's
 Stablization for transport
don't move patient before stabilization of cervical
spine.
 In hospital
 Usual trauma protocol
 Traction
rule of thumb is 5 pounds per spinal level above the
fracture/dislocation.
60-80 pounds are usually the upper limit in any case.

30. Pharmacologic treatment of SCI
1.Hypertension
adequate volume and normotension
2. Methylprednislone
within 8 hours of the SCI protocol
30mg/kg initial IV bolus over 15 minutes
followed by a 45 minute pause,
and then a 5.4 mg/kg/hr continuous infusion.
3. Naloxone

31. Cervical Spine Imaging Options
– Plain films
• AP, lateral and open mouth view
– Optional: Oblique and Swimmer’s
– CT
• Better for occult fractures
– MRI
• Very good for spinal cord, soft tissue and ligamentous
injuries
– Flexion-Extension Plain Films
• to determine stability

32. Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue

33. Adequacy
• Must visualize entire C-spine
• A film that does not show the
upper border of T1 is
inadequate
• Caudal traction on the arms
may help
• If can not, get swimmer’s
view or CT

34. Swimmer’s view

35. Alignment
• The anterior vertebral line,
posterior vertebral line, and
spinolaminar line should have
a smooth curve with no steps
or discontinuities
• Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be due
to rotation
• A step-off of >3.5mm is
significant anywhere

36. Lateral Cervical Spine X-Ray
• Anterior subluxation of one
vertebra on another indicates
facet dislocation
– < 50% of the width of a
vertebral body  unilateral
facet dislocation
– > 50%  bilateral facet
dislocation

37. Bones

38. Disc
• Disc Spaces
– Should be
uniform
• Assess spaces
between the
spinous processes

39. 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)

40. Open mouth view
• Adequacy: all of the
dens and lateral
borders of C1 & C2
• Alignment: lateral
masses of C1 and C2
• Bone: Inspect dens
for lucent fracture
lines

41. Spinal and Neurogenic shock

43. Odontoid Anatomy
 Steele's rule of thirds
The dens,
subarachnoid space,
and spinal cord
each occupy 1/3 of the area of the canal at the
level of the atlas.

44. Ligaments
External
1. posterior occipito-
atlantal ligament
(ligamentum flavum
ends at C1).
2. anterior occipito-
atlantal ligament.
3. ligamentum nuchae.
4. anterior longitudinal
ligament.
Internal
1. cruciform
ligament( transverse
ligament )
2. accessory ligaments
3. apical ligament
4. alar ligaments
5. posterior longitudinal
ligament
( tectorial membane )

46. Types of injuries

47. Atlas fractures
 cervicomedullary junction
remains unchanged because
of capacity of spinal canal.
 Jefferson’s fracture
 Burst fracture of C1 ring
 cervical spine is subjected to a
n axial load, as would occur fr
om a direct blow to the top of
the head
 Unstable fracture
 Need CT scan

48. Imaging
 Spence's Rule
If, on plain films, the distance of excursion of
lateral masses is 7 mm or more, there is a
transverse ligament rupture.

49. Treatment
 Halo immobilization in virtually all cases except
when Spence's rule exceeded

50. Odontoid Fractures
 Odontoid fractures
are the M/C
fractures of C2.

52. Classification

53. Clinical Features
 need high index of suspicion in all trauma
patients
 many signs and symptoms are non-specific
 vertebral artery compression may cause brain
stem ischemic symptoms.
 most patients unwilling to go from supine to
sitting position without supporting their heads
with their hands.

54. Odontoid Fracture Type II

55. Odontoid Fracture Type III

56. Treatment and results
 Halo traction, maximum of 5-10 pounds to
achieve reduction
 Surgery
Type I : no fusion required
Type III : no fusion required
(>90% fuse with Halo immobilization)
Type II : several factors important in
decision making

57. 1. Patient age.
sixty years of age is the usually quoted cutoff
for conservative management.
2. Displacement
If >6 mm and >60 years, 85% nonunion rate.
3. Age of fracture
greater than 2 weeks seems to be the cutoff
for high union rate

58. Hangman's Fracture
 Unstable
 Hyperextension injury
 Pathophysiology and Classification
Hangman's fracture involves a bilateral arch
fracture of C2 (pars interarticularis i.e, the
pedicle) with variable C2 on C3
displacement.

61. Treatment
 type I may be treated in a rigid collar for
12 weeks.
 remainder are all treated initially with Halo
immobilization.
 up to 5% will eventually require surgery.

62. Surgical Procedures
1. C1-C3 arthrodesis
2. C2 pedicle screws.
3. C2-C3 anterior discectomy with fusion
and plate.

64. Classification

65. Flexion Dislocation Injuries
A) unilateral facet
subluxation
B) bilateral facet
dislocation

67. Indications for surgery
1. failure to obtain reduction
2. failure to maintain reduction
3. pseudoarthrosis
4. purely ligamentous injury
5. re-subluxation
6. any patient with jumped facets

68. Flexion Compression Injuries
A) wedge compression
B) teardrop flexion fracture

69. Flexion Teardrop Fracture
• Flexion injury causing a
fracture of the
anteroinferior portion of
the vertebral body
• Unstable because usually
associated with posterior
ligamentous injury

70. Compression Burst Fractures
 characterized by axial
loading injuries to a
spine which is held in
a neutral or very
slightly flexed
position.
 immobilized by
traction with a Halo
vest.

71. Extension Injuries
 may occur either in distraction or compression.

72. Surgical Considerations
 absolute Indications
1. inability to obtain reduction
2. inability to maintain reduction
 indications for emergent surgery
1. progression of neurological deficit
2. complete myelographic or MRI CSF block
3. fragments in spinal canal in incomplete SCI
4. necessity for decompressing a cervical nerve root
5. open or penetrating trauma
6. non-reducible fractures

73. Contraindications for emergent
surgery
1. complete SCI
2. central cord syndrome.
3. medically unstable patient.

74. Surgical techniques
 posterior approaches
 anterior approaches
 cervical orthoses

76. Epidemiology
 represent 40% of all spine fractures
 majority due to motor vehicle accidents.
 grouped into
thoracic (T1-T10)
thoracolumbar (T11-L1)
lumbar fractures (L2-L5)
 60% occur between T12 and L2

77. Biomechanics
 In general,
compression causes burst fractures,
flexion causes wedge fractures,
rotation causes fracture dislocations,
shear causes seatbelt type fractures.

78.  thoracic region is inherently more stable
because of the rib cage and ligaments
linking the ribs and spine.
 the three column model states that failure of
two or more columns results in instability.
 the middle column is crucial, its mode of
failure distinguishes the four types of spine
fractures.

79. Imaging
 most important initial study is a complete
plain film series of the spine.
 5-20% of fractures are multiple.
 CT is used to define the bony anatomy in the
injured area.
 MRI essential to define spinal cord anatomy
and also for assessing ligamentous injury.

81. Flexion Compression Fractures
 most common type of fracture.
 failure of the anterior column due to flexion and
compression.
 a minimum of 30% loss of ventral height is
necessary to appreciate a kyphotic deformity
on x-rays.

82.  generally considered
stable.
 usually managed
with
bedrest
analgesics
early mobilization

83. Burst Fractures
 17% of major spinal fractures
 between T1-T10, most burst fractures are
associated with complete neurological deficit.
 bony fragments may be retropulsed into the
canal (25% of cases) and associated
fractures of the posterior elements are
common.
 failure of anterior and middle column defines
these as unstable.

85. Management
 those fractures with canal compromise in the
presence of neurological deficit should be
treated with surgical decompression and
fusion.

86. the treatment of burst fractures with canal
compromise and no neurological deficit is
controversial.
generally, management is based upon
determination of stability.
those fractures with >50% loss of vertebral
body height, or if the posterior column injury
includes a facet fracture or dislocation are
considered unstable.
commonly sited indications for surgery are
either,
i) angular deformity >15-40 degrees
ii) canal compromise >40-70%

89. Seat Belt Injuries
 6% of major spinal
injuries.
 caused by
hyperflexion and
distraction of the
posterior elements.

90.  the middle and posterior columns fail in
distraction with an intact anterior hinge.
 unstable in flexion but will not present with an
anterior subluxation, which would indicate
that the ALL is disrupted
(i.e. a fracture-dislocation).
 PLL is also intact and sometimes fracture
fragments are moved back from the canal
simply by distraction.

91. Management
 treatment of mainly osseous injuries is
bracing while mainly ligamentous injuries are
treated with posterior fusion.

92. Fracture Dislocations
 19% of major spinal
fractures.
 anterior and cranial
displacement of the
superior vertebral body
with failure of all three
columns.

93. Extension Distraction Fractures
 rare injuries.
 hyperextension force tears the ALL and leads
to separation of the disc.
 all are unstable and require fixation.

94. Treatment
 By Degree
according to Denis,
first degree is mechanical instability,
second degree is neurolgical,
and third is both.

95.  first degree: manage with external orthosis
i) >30 degree wedge compression fracture
ii) Seat belt injuries.
 second degree: mixed category
 third degree: all require surgery
i) fracture dislocations
ii) burst fractures who fail non-operative management
iii) burst fractures who develop new neurological deficit

96. Non-operative Therapy
 external orthosis for 8-12 weeks
serial radiographs every 2-3 weeks for the first 3
months,
then
4-6 week intervals until 6 months
and
at 3 month intervals for 1 year.

97. Indications for operative therapy