This document provides an overview of spinal injuries including: 1. It defines spinal injuries as injuries to the spinal column, spinal cord, or both and classifies them. 2. It discusses the epidemiology, mechanisms, clinical features, investigations, diagnosis, management, and prognosis of spinal injuries. 3. It describes the anatomy and functions of the spine, mechanisms of primary and secondary spinal cord injury, and factors that affect the severity of spinal cord lesions.

1. CME ON
Spinal Injury
And It’s Management
Prepared by -
Dr. Md Nazrul Islam, MBBS, M.sc.
Supervised by -
Dr. Sk. Abbas Uddin Ahmed
MS (Ortho), AO(Basic), AO(Spine).
Presenting by -
Dr. Abdul Hannan
From -
Department Of Orthopaedic & Traumatology,
Shaheed Suhrawardy Medical College Hospital. Dhaka.
1

2. Spinal Injury & its Management

3. Spinal Injury & its Management
Over view
Functions of spine
Definition of spinal injury
Anatomy of human spine
Classification of spinal injury
Epidemiology
Pathophysiology of spinal injury
Clinical features of spinal injury
Investigations
Diagnosis
Management
Prognosis
Rehabilitations
Conclusions

4. Spinal Injury & its Management
The spine has many functions, the main ones
are listed below-
1.To provide protection of the spinal cord
and associated nerves
2.To allow for movement
3.To support our body frame in an upright
position
4. To allow for flexibility
5. To provide a structural foundation for the
shoulder girdle and the pelvic girdles
6. To act as shock absorbers from load-
bearing
7. To provide a structural base for rib
attachments which protect the heart and
lungs.

5. Spinal Injury & its Management
Spinal Injuries Definition Of Spinal
Injury:
“ Spinal injury” may be defined
as-
Injury to the Spinal column (Bony
Column)/Spinal Cord,
or both of them.
Spinal injury can be divided into-
 Spinal Column(Bony)Injury.
 Spinal Cord injury.
 Combined (Both Column &
Cord) Injury.

6. Spinal Injury & its Management
 Bony spinal injuries may or may not
Spinal Column be associated with spinal cord injury
Injury  These bony injuries include:
 Compression fractures of the
vertebrae
 Comminuted fractures of the
vertebrae
 Subluxation (partial dislocation) of
the vertebrae
 Other injuries may include:
 Sprains- over-stretching or tearing of
ligaments
 Strains- over-stretching or tearing of
the muscles.

7. Spinal Injury & its Management
Spinal Cord Injury  Cutting, compression, or stretching
of the spinal cord
 Causing loss of distal function,
sensation, or motion
 Caused by:
 Unstable or sharp bony fragments
pushing on the cord, or
 Pressure from bone fragments or
swelling that interrupts the blood
supply to the cord causing
ischemia.

8. Spinal Injury & its Management
Epidemiology
 50% of SCI’s are complete
 50-60% of SCI’s are cervical
 Immediate mortality for complete cervical
SCI ~ 50%
Risk factors:  Occurs primarily in young males (> 75%
Alcohol intoxication of cases)
Drug abuse  Half of these injuries result from MVAs
Participation in high-
risk activities:
 2/3 of patients are < 30 years old
Diving  Other sources of SCI: Falls, sporting
Contact sports and industrial accidents, gunshot wounds.
Osteoporosis  Most common vertebrae involved are
C5, C6, C7, T12, and L1 because they
have the greatest ROM. 9

9. Spinal Injury & its Management
Epidemiology
Incidence
 10 - 15 per million
 18 - 35 years
 Male - 3:1
 RTA 51% - cars
 Domestic 16%
 Industrial 11%
 Sports 16% - diving incidents
 Self harm 5%

10. Spinal Injury & its Management
Types of Spinal Injury-
Cervical 40%
Thoracic 10%
Lumbar 3%
Dorso lumbar 35%
Any 14%

11. Spinal Injury & its Management
Incomplete injury:
Some motor or sensory functions is spared
distal to the cord injury. Voluntary sphincter
contraction, toe flexor contraction –present.
Prognosis-Good’
Complete injury:
Total motor & sensory loss distal to the injury
after Spinal shock (usually lasts for 24-48
hrs) is over. When the bulbo cavernosus
reflex is positive & no sacral sensation or
motor function has returned, paralysis will
be permanent & complete in most patients.
11

12. PATTERNS OF MULTIPLE SPINAL
INJURY :
Pattern: A. Primary lesion occur between
C5 & C7 with secondary injuries at
T12 or the lumber spine.
Pattern : B. Primary injury at T2-T4 with
secondary injury in cervical spine.
Pattern : C.. Primary injury occur
between T12 & L2 with secondary
injuries from L4-L5.

13. CLINICAL INSTABILITY
Acute:
Caused by bone or ligament
disruption that places the normal
elements in danger of injury with any
subsequent loading deformity.
Chronic:
Result of progressive deformity that
may cause neurological deterioration.

14. Spinal Injury & its Management
Predisposing factors
Degenerative Disease Of Spine
Spinal Canal Stenosis
Ankylosing Spondylitis
Down's Syndrome
Klippel-feil Syndrome
Arnold-chiari Malformation
Metastatic CA
Osteomyelitis
Rheumatoid Arthritis.
14

15. Spinal Injury & its Management
Spine consists of alternating
 Bony vertebrae
 Fibrocartilaginous disc
 Supported by musculature.
Motion segment – Two adjacent
vertebrae with intervening disc.

16. Spinal Injury & its Management
Anatomy of the spine is usually
described by dividing up the spine
(Bony vertebrae) into 3 major bony
sections:
 The cervical,
The thoracic, and
The lumbar spine in which the spinal
cord is embedded.
(Below the lumbar spine is a bone
called the sacrum, which is part of
the pelvis).
Each section is made up of individual
bones called vertebrae. There are 7
cervical vertebrae, 12 thoracic
vertebrae, and 5 lumbar vertebrae.

17. Spinal Injury & its Management
Stability of Spine-
• Anterior column = anterior 2/3 of
the vertebral body, disc, and annulus,
and the anterior longitudinal ligament)
• Middle column = posterior 1/3 of
the vertebral body, disc, annulus, and
the posterior longitudinal ligament
• Posterior column = pedicles, laminae,
facets, capsule, and the interspinous
and supraspinous ligament.
injury is said to be stable if only one
of the columns is involved.
damage to two or more columns or
risking neurological injury (ie damage
to the middle column) - unstable. 5

18. Spinal Injury & its Management
Most likely to occur at sites of Primary mechanism of cord injury can
maximum mobility
•Adults C6
be due to four kinds of mechanical
•Children <8 yrs old C2. forces.
a. Impact with persisting compression e.
g. fractures, dislocations, and disc
herniations.
b. Impact with no persisting compression
e. g. hyperextersion injuries.
c. Distraction e. g. hyperflexion injuries.
d. Laceration/ Transection: Penetrating
injuries, fracture dislocation.
8

19. Spinal Injury & its Management
Pathophysiology of spinal
cord injury:
Secondary injury mechanisms that may be
involved are:
a. Systemic shock: Profound hypotension, and
bradycardia (often lasting for days) follows
cord injury and there may be a compromise of
an already damaged cord.
b. Local microcirculatory damage: may be due
to mechanical disruption of capillaries,
hemorrhage, thrombosis and loss of
autoregulation.
c. Biochemical damage: may occur due to
excitotoxin release (glutamate), free radical
production, arachidonic acid release, lipid
peroxidation, eicosanoid production, cytokines
and electrolyte shifts.

20. Spinal Injury & its Management
Primary injury
25% of spinal cord injuries occur after primary
injury.
Primary injury results from focal injuries (eg
avulsion, contusion, laceration and intra-
parenchymal hemorrhage) and diffuse lesions
(e.g. concussive and diffuse axonal injury).
Further mechanical disruption can result from
external compression or angulation and
ischemic damage from occlusion of arterial
supply.

21. Spinal Injury & its Management
Secondary injury
Results from:

•Cellular hypoxia Immediately after an acute spinal cord
•Oligaemia injury major reduction in blood flow occurs
at the level of the lesion. Becomes
progressively worse over the first few hours
if left untreated. Pathophysiology
underlying this ischaemia is unclear but
involves both systemic and local effects.
Putative local mechanisms include
vasospasm, endothelial swelling or damage,
haemorrhage causing obstruction of small
blood vessels, loss of autoregulation and
impaired venous drainage.
21

22. Spinal Injury & its Management
Secondary injury-
Secondary Injury Cascade
Current understanding
22

23. Spinal Injury & its Management
 Primary Neurological damage
Direct trauma, haematoma &
SCIWORA < 8yrs old
In 4hrs - Infarction of white matter
occurs
In 8hrs - Infarction of grey matter
and irreversible paralysis
 Secondary damage
Hypoxia
Hypoperfusion
Neurogenic shock
Spinal shock

24. Spinal Injury & its Management
Factors affecting the severity of
a spinal lesion-
Loss of neural tissue - obvious
Vertical level – Higher up, the
greater the damage
Transverse plane – What Diameter
has a lesion

25. Spinal Injury & its Management
Common features of spinal
injuries are-
Pain
Breathing difficulty
Sensitivity to stimuli
Muscle spasms
Loss of sensation
Loss of reflex function
Loss of autonomic activity
Loss of bowel control
Loss of bladder control
Sexual dysfunction
Loss of function, such as mobility or sensation
Paralysis

26. Spinal Injury & its Management
“Level" of cord lesion is conventionally the
most caudal location with normal motor and
sensory function.
Motor level = the last level with at least 3/5
(against gravity) function
NB: this is the most important for
clinical purposes
Sensory level = the last level with preserved
sensation
Radiographic level = the level of fracture on
plain XRays / CT scan / MRI
NB: spine level does not correspond to
spinal cord level below the cervical
region.

27. Spinal Injury & its Management
 Spinal shock may mimic a complete cord
lesion with total loss of motor and sensory
function distal to injury. However if lesion is
incomplete some function will return
 99% of patients with a complete lesion over
24 h will not show functional recovery
 Patients with partial lesion may regain
substantial or even normal neurological function
even though the initial neurological deficit may
be severe
 Presence of bulbocavernous reflex or anal-
cutaneous reflex indicates sacral sparing and a
more favorable prognosis.

28. Spinal Injury & its Management
A. Clinical laboratory tests.
Laboratory tests will be guided by
clinical assessment of patient (history
and physical examination).
 In addition to routine investigations
diagnostic imaging is very important.
B. Diagnostic imaging.
1. X-RAY
2. CT SCAN
3. MRI

29. Spinal Injury & its Management
Indications for screening radiology. History of
trauma and:
Not fully conscious
Drowsy or intoxicated
Focal neurological deficit
Midline cervical tenderness
Other painful injury that may mask neck pain,
particularly fractures
Screening radiology of choice is CT of spine.
Additional indications are-
oExtremes of age
oMechanism of injury highly suggestive of
cervical spine injury
oSignificant facial trauma
Sensitivity approximately 98% and considerably
higher than plain radiography. May miss soft tissue
injury and spinal cord injury in the absence of bony
injury.

30. Spinal Injury & its Management
Although CT may miss soft tissue and
spinal cord injury, MRI is a sensitive
alternative method.
Almost never an emergency
Exception: cauda equina
syndrome
Shows tumors and soft tissues (e.g.,
herniated discs) much better than CT
scan.
Risk of transfer to MRI ability of MRI to
detect soft tissue injury may fall after
72 hour.
25

31. Spinal Injury & its Management SCIWORA
(spinal cord injury without
radiologic abnormality)
The term SCIWORA (spinal cord injury without
radiologic abnormality) originally referred to
Incidence 3-5% (x-ray/CT) spinal cord injury without radiographic or CT
Higher incidence in paediatric evidence of fracture or dislocation.
population (34.8%)- However with the advent of MRI, the term has
The relatively large size of the become ambiguous. Findings on MRI such as
head. inherent skeletal mobility. intervertebral disk rupture, spinal epidural
cord vulnerable to damage. hematoma, cord contusion, and hematomyelia
Higher incidence above 60 yo-
have all been recognized as causing primary or
Posterior vertebral spurs due to
spondylosis. Ligamentum flavum secondary spinal cord injury.
bulging due to loss of disc height. SCIWORA should now be more correctly
Risk of central cord syndrome after renamed as "spinal cord injury without neuro-
hyperextension injury. imaging abnormality" and recognize that its
prognosis is actually better than patients with
spinal cord injury and radiologic evidence of
traumatic injury.
25

32. History-
1. Mechanism of injury
2. Misdiagnosis - head injury, acute
alcoholic intoxication and multiple
injuries.
3.Decreased level of consciousness
or comatose patients may not
complain of neck pain.
4. Profuse bleeding from face and
scalp may divert attention from
cervical spine injury
20

33. General examination:
a) Head and ear
b) Spinous process and interspinous
ligaments palpation
c) Elbows may be flexed if a spinal cord
injury causes loss of function below biceps
and may be extended if the paralysis is
higher.
d) Penile erection and incontinence of the
bowel and bladder- significant spinal
injury.
e) Flaccid paralysis of the extremities –
Quadriplegia
f) Chest abdomen and extremities – Other
injuries.
21

34.  Accurate and detailed neurological
evaluation – very important
 Level of consciousness- Pupillary size and
reaction, epidural or subdural haematoma,
depressed skull fracture.
 Evaluation of sensory (pinprick), motor and
reflex function.
 Important dermatome landmarks are-
• Nipple line –T4
• Xiphoid process-T7
• Umbilicus –T10
• Inguinal region –T12,L1
• Perineum and peri-anal region (S2,S3&S4)
22

35. Pre-Hospital
Management.
Hospital
Management.
35

36. Primary(Pre-hospital)
management-
Initial treatment of patients with cord injury
focuses on two aspects - preventing further
damage and resuscitation.
Immobilization with a hard cervical collar (in case of
cervical spine injuries) and care in transportation of
patient is of paramount importance if the spine is
unstable.
Resuscitation is aimed at airway
maintenance, adequate oxygen saturation of
peripheral blood, restoring blood pressure
to acceptable limits, preventing
bradycardia, done simultaneously to prevent
any ischemic damage to the already
compromised cord. 36

37. Spinal Injury & its Management
Secondary (Hospital)
Management:
 Medical Management
 Conservative (General)-
 Conservative (Medical)-
 Surgical Management
Surgical Decompression
Surgical Stabilization
Fixation of Vertebra
Fixation of Spine
Artificial disc implantation

38. Spinal Injury & its Management
Conservative(General)-
Immediate Management-
Goals:
Resuscitation according to ATLS
guidelines
.
Determination of neurological injury
Prevention of neurological deterioration
Ongoing ID & Tx of assoc injuries
Prevention of complications
Initiation of definitive management for
vertebral column injury or SCI
32

39. Spinal Injury & its Management
Conservative(General)-
Aim is to prevent extension of primary
injury, to reduce secondary injury and to
treat complications-
Follow ATLS principles-
A irway; protect Spine
B reathing
C irculation
D isability, Dx and Rx shock
E xpose patient
And
 Treat Secondary survey.
32

40. Spinal Injury & its Management
Conservative(Medical)-
Conservative treatments of spinal disorders
have improved significantly over the years.
Of the many conservative non-surgical
treatments that are currently available, a few
of the most commonly practiced treatments
are -
•Epidural Steroid Injection
•Intradiscal thermoplasty (IDET)
•Nucleoplasty
•Facet Injections, and/or Medial Branch
Blockade
•Radio Frequency Rhizotomy or Denervation.
40

41. Spinal Injury & its Management
Surgical -
 Depending on the circumstances, when surgery is
required.
 Surgery may be considered if the spinal cord is
compressed and when the spine requires
stabilization.
 The surgeon decides the procedure that will
provide the greatest benefit for the patient.
 The common procedures which we perform are-
 Surgical Decompression
 Surgical Stabilization
o Spinal fusion
o Fixation of Vertebra
o Fixation of Spine
 Discectomy, foramenotomy and
laminectomy(Some times needed).
 Artificial disc implantation. 41

42. Surgical Decompression and/
or Fusion-
 Indications
o Decompression of the neural elements
(spinal cord/nerves)
o Stabilization of the bony elements (spine)
 Timing
o Emergent
 Incomplete lesions with progressive
neurologic deficit
o Elective
 Complete lesions (3-7 days post injury)
 Central cord syndrome (2-3 weeks post
injury).

43. Spinal Injury & its Management
Surgical -
43

44. Spinal Injury & its Management
Surgical -
33

45. Spinal Injury & its Management
Surgical–
Spinal fixation implants:
33

46. Spinal Injury & its Management
There are many complications of spinal Injury,
the followings are most common-
 Skin Breakdown
 Osteoporosis and Fractures:
 Pneumonia, Atelectasis, Aspiration:
 Heterotopic Ossification:
 Spasticity:
 Autonomic dysreflexia:
 Deep vein thrombosis:
 Cardiovascular disease:
 Syringomyelia-
 Neuropathic/Spinal Cord Pain-
 Respiratory Dysfunction-
 Miscellaneous
pressure sores, Greatly increase cost and morbidity
Pokilothermia in patients with lesion above T1
hyponatraemia common in first week.

47. Spinal Injury & its Management
Rehabilitation after spinal injury (SI) focuses
on the patient learning how to live life when
faced with physical, occupational, and
emotional challenges.
After SI, everything can change, and you
can face many issues including mobility,
regular exercise and maintaining a level of
fitness, communication challenges, and
activities of daily living.
Rehabilitation may be accomplished at a
hospital, outpatient clinic, home, or a
combination.

48. Spinal Injury & its Management
Accredited rehabilitation centers
provide SCI patients with a team of
professionals and many resources. Some
of the professionals include:
oOccupational Therapist
oPhysiatrist.
oPhysical Therapist:
oRehabilitation Nurse.
oSpeech and Language Pathologist.
oTherapeutic Recreational Specialist.
oVocational Rehabilitation Therapist.
oRehab Psychologist
36

49. Spinal Injury & its Management
39

50. Spinal Injury & its Management
Prognosis
 The main determinant of outcome is the patient's neurological
grade at the time of admission with patients having complete motor
and sensory myelopathy showing the worst prognosis.
 Other predictive factors include rectal tone status, admission blood
pressure and pulse status, reflexes, and medical and surgical
management since injury.
 The time course of recovery is also prolonged and recovery itself
often incomplete.
Taking all grades and locations into considerations a study concluded
that while the majority of cases improved within a year, even at 3
years post injury 23.3% continue to improve whereas 7.1%
deteriorated. The trend continued in the 5th year post injury also with
12.5% and 5.5% respectively showing further improvement and late
deterioration. Hence prolonged rehabilitation at a comprehensive
spinal rehabilitation center is the management of spinal cord injuries.
50

51. Spinal Injury & its Management
“Neurological disorders are the most
complicated problems known to medical
science today, and we require the best
scientific minds and technology in order to
find cures.”
W. Dalton Dietrich, Ph.D., scientific director,
The Miami Project to Cure Paralysis
40

52. Spinal Injury & its Management
 Pre-hospital & hospital both phases are equally
important for SI management.
 Surgical intervention improves recovery period, quality of
life and Rehab, reduces morbidity/ mortality .
 SI is neglected and poorly managed. Research is sparse
and data is missing. The demographics, epidemiological
pattern of SC in the developing world is different from the
developed world and this should be considered while
formulating polices for the SI in future.
 Trauma evacuation protocols need to be developed and
pre hospital care of suspected SI patient should be
improved.
 Regional and national spinal injury centers providing
comprehensive treatment and multidisciplinary rehabilitation
should be established.

53. Spinal Injury & its Management
From-
Department Of Orthopedics’ & Traumatology
Shaheed Suhrawardy Medical College Hospital.

54. Spinal Injury & its Management
Associate Prof. Dr. P. C. Debenath
Associate Prof. Dr. Sheikh Abbas Uddin.
Associate Prof. Dr. Ziaul Haq
Associate Prof. Dr. Shamimul Haq
Associate Prof. Dr. Monowarul Islam
Associate Surgeon Dr. Md. Aminur Rahman
Assistant Prof. Dr. Kazi Shamimuzzaman
Assistant Prof. Dr. A T M Bahar Uddin
Dr. Abdul Hannan
And
Dr. Md Nazrul Islam
Resident Surgeon,
Department of Orthopedic & Traumatology.
Shaheed Suhrawardy Medical College Hospital.
3/26/2011
54