Spinal trauma can cause permanent injury to the spinal cord. It is important to properly immobilize the spine after injury to prevent further damage. Common causes of spinal injury include motor vehicle accidents, falls, sports injuries, and improper handling after the injury occurs. Early management focuses on stabilizing the spine and preventing further neurological deterioration through careful patient handling and avoiding hypotension.

1. Spinal Trauma
BY
DR. SHAHERYAR AZIZ

2. Introduction
• Annually 15,000 permanent spinal cord injuries
• Commonly men 16–30 years old
• Mechanism of Injury
–
–
–
–
Vehicle crashes: 48%
Falls: 21%
Penetrating trauma: 15%
Sports injury: 14%
• 25% of all spinal cord injuries occur from improper handling of the spine
and patient after injury.
– ASSUME based upon MOI that patients have a spinal injury.
– MANAGE ALL spinal injuries with immediate and continued care.
• Best form of care is public safety and prevention programs.

3. Functional anatomy
• Function
• Skeletal support structure
• Major portion of axial skeleton
• Protective container for spinal cord
• Vertebral Body
• Major weight-bearing component
• Anterior to other vertebrae components

4. Functional anatomy
• The lumbar and low thoracic vertebrae are larger and
wider.
• The spinous processes are more horizontal.
• Thoracolumber junction is more susceptible to injury
because there is a fulcrum of increased motion.
• Cauda equina begins at L1-L2. Lesions below L1 have a
better prognosis as nerve roots , not cord are affected.

5. Bony anatomy

6. Bony anatomy

7. Bony anatomy

8. Discs

9. Ligaments

10. Spinal Meninges
• Layers
• Dura mater
• Arachnoid
• Pia mater
• Cover entire spinal cord and peripheral nerve roots
that exit
• CSF fills the subarachnoid space
• Exchange of nutrients and waste products
• Absorbs shocks of sudden movement

11. Spinal Meninges

12. Spinal Cord
Function
Transmits sensory input from body to the brain
Conducts motor impulses from brain to muscles and organs
Reflex Center
• Intercepts sensory signals and initiates a reflex signal
Growth
Fetus
• Entire cord fills entire spinal foramen
Adult
– The lower tip of the spinal cord (conus medullaris) is usually at the
level of the L1 vertebra.
– Spinal nerves below this level comprise the cauda equina.

15. Subdivision of ANS
– Parasympathetic, “Feed
and Breed”
• Controls rest and
regeneration
• Peripheral nerve roots
from the sacral and
cranial nerves
• Major Functions
– Slows heart rate
– Increases digestive
system activity
– Plays a role in sexual
stimulation
– Sympathetic, “Fight or
Flight”
• Increases metabolic rate
• Branches from nerves in the
thoracic and lumbar regions
• Major Functions
– Decreases organ and
digestive system activity
» Vasoconstriction
– Release of epinephrine and
norepinephrine
» Reduces venous blood
volume
» Increases peripheral
vascular resistance
– Increases heart rate
– Increases cardiac output

16. •
•
•
•
•
Upper Motor Neurons
UMN
Originate in cerebral cortex
Project downward
Result in skeletal muscle
movement
• Injury = SPASTIC paralysis
• Lower Motor Neurons
• LMN
• Originate at each vertebral
level
• Project to specific parts of the
body
• Result in movement
/sensation
• Injury = FLACCID paralysis
.

17. Spinal Nerves
– 31 pairs of nerves that originate
along the spinal cord from anterior
and posterior nerve roots
–
–
–
–
–
8 cervical
12 Thoracic
5 Lumbar
5 Sacral
1 Coccygeal
Sensory & motor functions
Travel through intervertebral
foramina
 Each pair has 2 dorsal and 2 ventral
roots
Ventral roots: motor impulses from

20. Dermatomes
• Dermatomes
– Topographical region of
the body surface
innervated by one nerve
root
Key locations are :-

21. Dermatomes

22. Myotomes
• Muscle and tissue of the body innervated by spinal nerve roots
•
•
•
•
•
•
•
•
•
•
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
Flex Elbows (biceps , brachialis)
Wrist extensors (extensor carpi radialis longus , brevis)
Extend Elbow (triceps)
Finger flexors (flexor digitorum profundus to the middle fingure)
Small finger abductors (abductor digiti minimi)
Hip Flexion (iliopsoas)
Knee Extension (quadriceps)
Ankle Dorsiflexion (tibialis anterior)
Long toe extensors (extensor hallucis longus)
Ankle planterflexors (gastrocnemius , soleus)

23. Myotomes

25. Mechanisms of Spinal Injury
– Extremes of Motion
Hyperextension:
• Common in the neck
• Anterior ligaments and disc may be damaged.
Hyperflexion:
• If posterior ligament is intact , wedging of vertebral body occurs.If torn , may
cause subluxation.
Axial compression:
• Causes burst fractures. Bony fragments may be pushed into spinal canal.
Flexion with rotation:
• Causes dislocation with or without fracture.
Flexion with posterior distraction:
• May disrupt middle and posterior column
Shear

28. 3-column concept
•
The 3-column concept of the spine as defined by Denis is widely used as the
conceptual framework for diagnosing acute overt spinal instability.
•
The anterior column consists of the anterior vertebral body (usually anterior twothirds), the anterior annulus, and the anterior longitudinal ligament.
•
The middle column refers to the posterior wall of the vertebral body, the posterior
annulus, and the posterior longitudinal ligament.
•
The posterior column refers to the posterior ligamentous complex that connects
adjacent neural arches, consisting of facet capsules, ligamentum flavum,
interspinous ligament, and supraspinous ligament.
•
Failure of two or more columns generally results in instability.

30. .
• Stable Injuries
• Vertebral components won’t be displaced by normal movement.
• An undamaged spinal cord is not in danger.
• There is no development of incapacitating deformity or pain.
• Unstable Injuries
•
•
•
•
•
Further displacement of the injury may occur.
Loss of 50% of vertebral height.
Angulation of thoracolumbar junction of > 20 degrees.
Failure of at least 2 of Denis’s 3 columns.
Compression fracture of three sequential vertebrae can lead to post
traumatic kyphosis.

31. .
• In this context, a simple compression wedge fracture occurs due to failure
of the anterior column with preservation of the middle column (stable).
• On the other hand, a burst fracture occurs due to compression failure of
both anterior and middle columns (usually unstable), often resulting in
bone retropulsion into spinal canal.
• A seat-belt type injury is attributed to distraction failure of the posterior
and middle columns with hinging of an intact anterior column (unstable).
•
Fracture-dislocations involve failure of all 3 columns and are considered
highly unstable.

32. Compressed vertebral fracture

33. Burst fracture

34. Spinal Cord Injury
– Concussion
• Similar to cerebral concussion
• Temporary and transient disruption of cord function
– Contusion
• Bruising of the cord
• Tissue damage, vascular leakage, and swelling
– Compression
• Secondary to:
–
–
–
–
Displacement of the vertebrae
Herniation of intervertebral disk
Displacement of vertebral bone fragment
Swelling from adjacent tissue
– Laceration
• Causes
– Bony fragments driven into the vertebral foramen
– Cord may be stretched to the point of tearing
– Hemorrhage
• Associated with contusion, laceration, or stretching

35. Symptoms and Signs
Neurologic function
Above the injury
Below the injury
•
intact.
absent or markedly diminished.
Specific manifestations depend on the exact level and whether cord injury
is complete or incomplete.
• Vertebral injury typically is painful, but patients who are distracted by
other painful injuries (eg, long bone fractures) or whose level of
consciousness is altered by intoxicants or head injury may not complain of
pain.

36. Location of Injury
Possible Effects
At or above C5
Respiratory paralysis and quadriplegia
Between C5&c6
Paralysis of legs, wrists, and hands; weakened
shoulder abduction and elbow flexion; loss of
brachioradialis reflex
C6-C7
Paralysis of legs, wrists, and hands, but
shoulder movement and elbow flexion usually
possible; loss of biceps jerk reflex
C7-C8
Paralysis of legs and hands
C8-T1
With transverse lesions, Horner's syndrome
(ptosis, miotic pupils, facial anhidrosis),
paralysis of legs
T1-T12
Paralysis of leg muscles above and below the
knee
At T12 to L1
Paralysis below the knee
Cauda equina
Hyporeflexic or areflexic paresis of the lower
extremities, usually pain and hyperesthesia in
the distribution of the nerve roots, and usually
loss of bowel and bladder control
At S3 to S5 or
conus
medullaris at L1
Complete loss of bowel and bladder control
•
.

37. Conus medullaris
&
cauda equina

38. Conus Medullaris Syndrome
Cauda Equina Syndrome
Presentatio Sudden and bilateral
n
Gradual and unilateral
Reflexes
Knee jerks preserved but ankle jerks affected
Both ankle and knee jerks affected
Radicular
pain
Less severe
More severe
Low back
pain
More
Less
Sensory
symptoms
and signs
Numbness tends to be more localized to perianal area; Numbness tends to be more localized to saddle area;
symmetrical and bilateral; sensory dissociation occurs asymmetrical, may be unilateral; no sensory
dissociation; loss of sensation in specific dermatomes
in lower extremities with numbness and paresthesia;
possible numbness in pubic area, including glans penis
or clitoris
Motor
strength
Typically symmetric, hyperreflexic distal paresis of
lower limbs that is less marked; fasciculations may be
present
Asymmetric areflexic paraplegia that is more marked;
fasciculations rare; atrophy more common
Impotence
Frequent
Less frequent; erectile dysfunction that includes
inability to have erection, inability to maintain
erection, lack of sensation in pubic area (including
glans penis or clitoris), and inability to ejaculate
Sphincter
Urinary retention and atonic anal sphincter cause
dysfunction overflow urinary incontinence and fecal incontinence;
Urinary retention; tends to present late in course of
disease

39. Complete cord injury
•
Transection leads to immediate, complete, flaccid paralysis (including loss of anal sphincter
tone), loss of all sensation and reflex activity, and autonomic dysfunction below the level of
the injury.
•
High cervical injury (at or above C5) , causing
Respiratory insufficiency especially in patients with injuries at or above C3.
Bradycardia and hypotension (neurogenic shock) .
Arrhythmias and BP instability may develop.
•
Flaccid paralysis gradually changes over hours or days to spastic paralysis with increased
deep tendon reflexes due to loss of descending inhibition.
•
Later, if the lumbosacral cord is intact, flexor muscle spasms appear and autonomic reflexes
return.

40. Incomplete cord injury:
• Partial motor and sensory loss occurs, and deep tendon reflexes may be exuberant.
• Rapid swelling of the cord results in total neurologic dysfunction resembling
complete cord injury (spinal shock )
– Anterior Cord Syndrome
• Flexion Compression.
• Loss of motor function and
sensation of pain, light touch, and
temperature below injury site
• Retain positional, and vibration
sensation
• Poor prognosis

41. – Central Cord Syndrome(age > 50)
• Hyperextension injuries.
• Motor and sensory loss affecting
upper extremities more.
• Fair prognosis

42. – Brown-Sequard’s Syndrome
.
•
•
•
•
Penetrating injury that affects one side of the cord
Ipsilateral motor loss vibration and position sense.
Contralateral pain and temperature sensation loss
Best prognosis

43. .
• Posterior Cord Syndrome
•
•
•
•
Least frequent syndrome
Injury to the posterior (dorsal) columns
Loss of proprioception
Pain, temperature, sensation and motor function below the level of the
lesion remain intact

44. Spinal Shock
Temporary insult to the cord
Affects body below the level of injury
Diaphragmatic breathing
Flaccid limbs
Warm periphery
Decr. Pain sensation
Reduced reflexis
Erection
Urinary retention
Decr. BP + Decr. Pluse rate = neurogenic
Decr. Body temp.
Return of bulbocavernosus reflex = end of spinal shock

45. • Neurogenic Shock
– Signs and Symptoms
•
•
•
•
•
.
Bradycardia
Hypotension
Cool, moist, and pale skin above the injury
Warm, dry, and flushed skin below the injury
Male: priapism
• Autonomic Hyperreflexia Syndrome
– Associated with the body’s response of the effects of spinal
shock
– Commonly associated with injuries at or above T-6
– Presentation
•
•
•
•
•
Sudden hypertension
Bradycardia
Pounding headache
Blurred vision
Sweating and flushing of skin above the point of injury

46. Grading of Spinal Cord Injury

47. Spinal Injury Impairment Scale
American Spinal Injury Association
Level
Impairment
A = Complete
No motor or sensory function, including in the sacral
segments S4–S5
B = Incomplete
Sensory but not motor function is preserved below the
neurologic level and includes the sacral segments
S4—S5
C = Incomplete
Motor function is preserved below the neurologic level,
1
and > ⁄2 of key muscles below neurologic level have
a muscle grade < 3
D = Incomplete
Motor function is preserved below the neurologic level,
1
and at least ⁄2 of key muscles below the neurologic
level have a muscle grade > 3
E = Normal
Motor and sensory function are normal

48. Management of the
Spinal Injury Patient
Objectives
•
•
•
•
Preserve neurological function.
Relieve reversible nerve or cord compression.
Stabilize the spine.
Rehabilitate the the patient.

49. DO NO HARM
An important goal is to prevent secondary injury to the spine or spinal
cord.

50. Prehospital care
• An important goal is to prevent secondary injury to the
spine or spinal cord. In unstable injuries, flexion or extension of
•
•
•
•
•
•
the spine can contuse or transect the cord.
Which can result in paraplegia, quadriplegia, or even death from
spinal injury.
Immobilize spine immediately.
A rigid collar should be used to immobilize the cervical spine.
Patients with thoracic or lumbar spine injuries should be shifted by
logroll technique on a flat ,firm padded back board in supine
position.
Transfer to a trauma center Immediately.
Pre hospital medical care should be directed at avoiding hypoxia
and hypotension, both of which can further stress the injured cord.

51. LOGROLL
Spinal trauma

52. Emergency department management
•
ABCs
•
Intubation if needed.
•
Spinal s stabilization.
•
secondary survey.
•
History – major accident , unconscious pt, fall from height , jerk to neck , head injury , facial injury.
•
Logroll – look for bruising , palpate for step and tenderness.
•
Look for associated injuries, such as brain, thoracic, or abdominal injuries.
•
Imaging; x-rays , CT , MRI.
•
repeated neurologic examination helps determine the presence of deficits its progression /resolution.
•
Hypotension and bradycardia may indicate neurogenic shock.
•
Maintain the systolic blood pressure at a value of at least 90 mm Hg with a heart rate of 60-100 beats
per minute.
• Bradycardia may be treated by the use of atropine.
•
Attempt to maintain urine output at a minimum of 30 mL/h. If all of the above parameters are difficult
to maintain, consider support with inotropic agents.
•
These patients are also at risk for hypothermia and should be warmed to maintain a core temperature of
at least 96°F. Place a Foley catheter to help with voiding.

53. .
– Fluid Challenge
• Isotonic solution: 20 mL/kg
– 250 mL initially
– Monitor response and repeat as needed
– Dopamine
• 2–20 mcg/kg/min titrated to blood pressure
– Atropine
• 0.5–1.0 mg q 3–5 min (maximum of 2.0 mg)
– Steroids (Methylprednisolone)
• Reduce swelling and pressure on cord
• Begin steroid therapy within 8 hours of the injury.
• The initial dose of methylprednisolone is 30 mg/kg administered over
15 minutes.
• Start an infusion for the maintenance dose of 5.4 mg/kg/h at the
beginning of the first hour and continue it through the 23rd hour.
.

54. Thoracolumber injury classification & severity score
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Fracture Mechanism
points
Compression fracture
1
Burst fracture
2
Translation/ rotation
3
Distraction
4
Neurological involvement
Intact
0
Nerve root
2
Cord , conus medullaris , incomplete
3
Cord , conus medullaris , complete
2
Cauda equina
3
Posterior ligamentous complex intregity
Intact
0
Injury suspected / indeterminate
2
Injured
3
Score< or equal to 3
non operative treatment
Score > or equal to 5
operative treatment
Score = 4
non operative/operative .
(depend upon comorbid / other injuries)

55. Management
With no neurological deficit:
• If stable-pain relief , collar or brace.
• If unstable-reduce and hold secure until bone / ligaments heal with
surgery or traction.
With complete sensory or motor loss:
• Usually an unstable injury
• Only consider conservative management for high thoracic injuries.
• Early operative stabilization to help with nursing , prevent spinal
deformity and pain.
• Speeds up rehab.
With incomplete neurological loss:
• Stable injury-conservative bed rest , brace.
• Unstable injury-early reduction and stabilization.

56. Surgical therapy
•
The goals of operative treatment are to decompress the spinal cord canal and to stabilize the
disrupted vertebral column.
•
Three basic approaches are used for surgical management of the thoracolumbar spine:
•
(1) the posterior approach, (2) the posterolateral approach, and (3) the anterior approach.
•
Selection of the best approach is guided by the anatomy of the fracture and the location of
spinal canal encroachment.
•
Also consider the need for stabilization procedures.
Categories of procedures for spine stabilization
•
The 4 basic types of stabilization procedures are
(1) posterior lumbar interspinous fusion,
(2) posterior rods,
(3) cage, and
(4) the Z-plate anterior thoracolumbar plating system. Each has different advantages and
disadvantages.

57. complicatons
Highest morbidity in first 2 weeks
Most common cause of morbidity and motility are:
 Respiratory insufficiency
 Paralytic ileus
 Urological complications.
 GI bleeds
 Pressure sores
 Joint contractures
 psychological

58. .
.