spinal trauma only

2.  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.

3.  The primary Injury
 When the skeletal structures fail to dissipate the energy of the primary
mechanical insult.
 Results in direct energy transfer to neuronal elements.
▪ Flexion
▪ Extension
▪ Axial Loading
▪ Rotation or traction
▪ Compression of the Cord
 Secondary Injury
 Hemorrhage, oedema, and Ischemia secondary to the insult.
 Therapeutic strategies are directed at reducing secondary injury.

4.  Extremes of Motion
Hyperextension:
▪ Common in the neck
▪ Anterior ligaments and disc may be damaged.
Hyper flexion:
▪ 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

6.  Neurologic function
 Above the injury: intact.
 Below the injury: 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 (e.g., long bone fractures) or whose level of consciousness is
altered by intoxicants or head injury may not complain of pain.

7. 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
 .

8.  Approach every patient in the same manner using AdvancedTrauma Life
Support Principles (ATLS).
 Assume every trauma patient has a spinal injury until proven otherwise.
 All Assessment, Resuscitation and life saving procedures must be performed
with full spinal immobilization.
 Signs of spinal Injury:
 Polytrauma patient
 Neurological Deficit
 Multiple Injuries
 Head Injuries
 Facial Injury
 High energy Injury
 Abdominal Bruising from a seatbelt.

10.  The Unconscious patient:
 Full Assessment of the spine is difficult.
 Definitive clearance of the spine many not be possible initially.
 Maintain Spinal Immobilization until MRI rules out injury.
 The Pain-free patient:
 There is no pain.
 Palpation of the spine is non-tender.
 Neurological examination is normal.
 There is pain free range of movement.
 The mechanism and velocity of injury should be determined at an early stage.

11.  Initial Assessment
 Be aware that spinal injury may mask signs of intra-abdominal injury.
 Identification of Shock
 Three types of Shock may occur in spinal trauma:
▪ Hypovolaemic Shock: Presents with hypotension, tachycardia, cold clammy
peripheries. Caused by hemorrhage; treated with appropriate fluid replacement.
▪ Neurogenic Shock: Hypotension w/ normal heart rate or bradycardia and warm
peripheries. Caused by unopposed vagal tone resulting from cervical spinal cord injury
above the level of the sympathetic outflow (C7/T1).
▪ Spinal Shock: Characterized by paralysis, hypotonia, and areflexia. Lasts for only 24
hours. Assess patient neurologically. When it starts to resolve bulbocavernosus reflex
returns.

12. Bulbocavernosus
reflex
The bulbocavernosus reflex (BCR) or
"Osinski reflex" is a polysynaptic reflex
that is useful in testing for spinal shock and
gaining information about the state of
spinal cord injuries (SCI)

13.  Spinal Examination
 Spine Log Roll must be performed to achieve proper examination.
 Inspect and palpate entire spine.
 Swelling, tenderness, palpable steps or gaps suggest a spinal injury.
 Note the presence of any wounds that might suggest penetrating
trauma.

14.  American Spinal Injury Association neurological evaluation system is used.
 Motor Function assesses key muscle groups. Grade (0-5)
 Sensory Function assesses dermatomal map. (Pinprick and light touch) Score: 0-2
 Rectal examination:
▪ Anal tone.
▪ Voluntary anal contraction.
▪ Perianal sensation.
 What should be known after complete neurological examination?
 Presence or absence of neurological injury.
 Probable level of injury.
 Injury is complete or incomplete.
 Level of impairment.

15. A Absent motor and sensory function.
B Sensory function present, motor function absent.
C Sensory function present, motor function present
but not useful. (MRC Grade<3/5)
D Sensory function present, motor function useful.
(MRC Grade≥3/5)
E Normal Function.

17.  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.

18.  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 )
 Central Cord Syndrome
 Brown-Sequard Syndrome
 Anterior Spinal syndrome
 Posterior Cord Syndrom
 Cauda Equina Syndrome

19.  Flexion Compression injuries to the cervical spine may
damage anterior spinal artery cutting off blood to anterior
2/3rd of spinal cord.
 Loss of motor function and sensation of pain, light touch, and
temperature below injury site
 Retain positional, and vibration sensation
 Poor prognosis

20.  Hyperextension of the cord results in pinching of the cord in
pre-existing degenerative narrowing od the spinal cord.
 Upper limbs and hands profoundly affected.
 Distal motor function in the legs usually spared.
 Fair Prognosis

21.  Penetrating injury that affects one side of the cord
 Ipsilateral motor loss vibration and position sense.
 Contralateral pain and temperature sensation loss
 Best prognosis

22.  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

24.  85% of significant spinal injuries will be seem on standard lateral cervical
spine.
 CT Scan should be obtained.
 Most Sensitive in spinal trauma.
 Complex patterns and fractures can be understood.
 MRI
 Best at visualizing soft-tissue elements of the spine.
 Possible to view spinal cord hemorrhage, epidural and prevertebral hematomas.
 Not good at assessing bony structures.
 In spinal traumas radiographs and CT scans usually give sufficient
information and MRI is not required.

25.  Objectives
 Preserve neurological function.
 Relieve reversible nerve or cord compression.
 Stabilize the spine.
 Rehabilitate the patient.
 An important goal is to prevent secondary injury to the
spine or spinal cord.

26.  The goals of operative treatment are to decompress the spinal cord
canal and to stabilize the disrupted vertebral column.
 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
4. The Z-plate anterior thoracolumbar plating system. Each has different advantages and
disadvantages.