1. Spinal injuries can range from stable compression fractures to unstable fracture-dislocations that involve failure of multiple spinal columns. A thorough history, physical exam, and imaging are needed to classify the injury and spinal stability. 2. Key considerations in management include immobilization to prevent further injury, intravenous fluids, medications like corticosteroids, and prompt referral to a spinal specialist. Complications can include neurological deficits, pressure sores, DVT, and respiratory issues. 3. Complete injuries result in total loss of motor and sensory function below the level of injury, while incomplete injuries involve a mixed or partial neurological picture. Grading systems like ASIA are used to document deficits and guide prognosis.

1. Spine trauma:
basics
BY DR. D. P. SWAMI

2. Spinal anatomy
Classifications
Stable vs unstable injury
Complete vs incomplete injury
Evaluating a patient with suspected spinal injury
Management
Overview

3. Verte
bral
Colu
mn

4. Anatomy
Corticospinal tract – controls motor power on SAME side
Spinothalamic tract – transmits pain & temp sensation from
OPPOSITE side
Dorsal columns – carries position sense (proprioception), vibration
sense and some light touch sensation from SAME side

7. Anatomy
Location of Spinal Injuries
55% in cervical region (mobile
& exposed)
15% in thoracic region (less
mobile & protected)
15% in thoracolumbar region
(fulcrum)
15% in lumbosacral region

8. Anatomy
Below C3, diameter of spinal canal is smaller
-vertebral column injuries more likely to produce spinal cord
injuries
Thoracolumbar junction:- inflexible thoracic spine meets
strong lumbar spine making it vulnerable to injury

9. Denis: 3 Column Concept of spinal
stability.
Thespinalcordcanbedivided into
threecolumns:
Anterior, middle and posterior.
Spinal stability is dependent on
at least two intact columns.
When two of the three columns
are disrupted, it will allow
abnormal segmental motion, i.e.
instability.
Failure of two or more
columns generally results in
instability.

10. Diagram
matic
represent
ation of
the Three
Column
Concept
of spinal
stability.
DPSDPS

11. Functional spinal unit
Functional spinal unit is
composed of
•two adjacent
vertebrae
•Facet joint
•inter vertebral disc
and
•intervening ligaments
This unit is responsible
for Movement of joint 4

12. ETIOLOGY
• High energy trauma
• Fall from height
• Sports accident
• Violent act, such as a gunshot wound
• osteoporosis
• tumors
• other underlying conditions that weaken
bone

14. COMPRESSION FRACTURE:
•Results from Anterior or lateral flexion
•Failure of anterior column
•The middle column is intact and acts as a
hinge.
• There may be a partial failure of the
posterior column, indicating the tension
forces at that level.
•Usually no Neurological deficits are noted.

15. 4 subtypeson basis
of end plate
involvement
•# of both end plates
•# of superior end
plate
•# of inferior end
plate
•both end plates
intact

16. Burst fractures
• Occurs due to Axial compression resulting
in Failure of anterior and middle column
• If posterior column involved results in
instability
• Most common at T/L junction

17. 5 subtypes on basis of
end plate involvement
• # of both end plates
• # of superior end plate
• #of inferior end plate
• both end plates intact
• Burst lateral flexion

18. FLEXION-DISTRACTION OR SEAT-BELT- TYPE
INJURY or CHANCE #
• Both posterior and
middle columns fail
due to hyper-flexion
and subsequent
tension forces.
• The anterior part of
the anterior column
may partially
damaged under
compression, but still
functions like a hinge.

19. Fracture- Dislocation
• Presents with failure of all three columns
under compression, tension, rotation, or
shear.
• It is similar to seat-belt-type injury.
However, the anterior hinge is also
disrupted and some degree of
dislocation is present.

20. Three subtypes of fracture-dislocations
based on mechanism of injury:
•flexion rotation
•Flexion-distraction
•Shear type

21. flexion rotation:
There is a
complete
disruption of the
posterior and
middle columns
under tension
and rotation.
•The anterior
column in rotation
or compression
and rotation.

22. Flexion-distraction
• Tension failure of
posterior and middle
columns .
•With tear of the
anterior annulus
fibrosus, and stripping
of the anterior
longitudinal ligament .
•Neurological
deficit(75%)

23. Shear :
•Shear failure of all
three columns,
•commonly in postero-
anterior direction
•All cases present with
neurologic deficit

24. AO/MAGREL CLASSIFICATION
B
C
1 2 3
A

25. Thoracolumbar Injury
Classification and Severity Score
1
1
3
4
POINTS
• FRACTURE MECHANISM
• Compression fracture
• Burst fracture
• Translation/rotation
• Distraction
• NEUROLOGICAL INVOLVEMENT
• Intact 0
• Nerve root 2
• Cord, conus medullaris, incomplete3
• Cord, conus medullaris, complete 2
• Cauda equina 3
• POSTERIOR LIGAMENTOUS COMPLEX
INTEGRITY
• Intact
• Injury suspected/indeterminate
0
2
3

26. SPINAL STABILITY
• Spinal injury is considered unstable if
normal physiological load cause further
neurological damage , chronic pain &
deformity
• Instability exists if any of two columns
are disrupted
• In T-L stability if middle column is intact,
# is usually stable .

27. Stable vs. Unstable Injuries
StableInjuries
Vertebral components won’t be displaced by
normal movement.
An undamaged spinal cord is not in danger.
Thereis 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.

28. Three Degrees of instability:
First degree : (Mechanical
instability): Severe compression #
Seat belt injury
Second degree: (Neurological
instability) Burst # with out
neurological deficit
Third degree : (Both)
Burst # with neurological deficit
Fracture dislocation

29. • Complete - flaccid paralysis + total loss of sensory &
motor functions
• Incomplete - mixed loss
- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome
36
Cord injury

30. Incomplete Cord Transection
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
CaudaEquina
Syndrome

31. Anterior Cord Syndrome
Flexion Compression injuries to the
cervical spine may damage anterior spinal
artery cutting off blood to anterior 2/3rd of
spinal cord.
Lossof motor function and sensation of pain,
light touch, and
temperature below injurysite
Retain positional, and vibration sensation
Poor prognosis
DPS

32. Central Cord Syndrome
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
DPS

33. Anterior Cord Syndrome
Flexion Compression injuries to the
cervical spine may damage anterior spinal
artery cutting off blood to anterior 2/3rd of
spinal cord.
Lossof motor function and sensation of pain,
light touch, and
temperature below injurysite
Retain positional, and vibration sensation
Poor prognosisDPS

34. 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

35. Cauda
Equina
Syndrom
e

36. Spinal Trauma: Management
Principles
1. Immobiisation
2. Intravenous fluids
3. Medications
4. Early advise, prompt referral/transfer
ED acute care priority: avoid secondary spinal injury

37. Spinal
Immobili
zation
IMMOBILISE

38. Spinal Trauma: Management
Principles
Immobilisation: protect from further spinal injury
cervical collar
long spinal board, bolsters and tape
remove from spinal board as soon as possible
(ideally < 2hours, BEWARE pressure pts & decubitus
ulcers)
logroll maintaining neutral alignment of entire spine (four or
more helpers required with av 70kg patient)

39. After arriving at ED, at least 5% with spinal injury experience
new symptoms or worsening of preexisting symptoms as a
result of –
secondary spinal injury
(ischaemia & progression of spinal cord
oedema)
poor immobilisation technique

40. Spinal Trauma: Management
Principles
Fluid resuscitation
• Maintenance fluids only unless shock
• If shocked –establish if hypovolaemic OR neurogenic
Insert IDC (during primary survey)
• Monitor urinary output
• Prevent bladder distension
Insert NGT
• Prevent gastric distension (+/- paralytic ileus)
• Prevent aspiration (sphincter paralysis)

41. Spinal Trauma: Management
Principles
Medications
 Corticosteriods - insufficient evidence for routine use
Aimed at reducing extent of permanent paralysis Most trials have
used high dose methylprednisolone
Improved motor neurological outcome up to one year post injury if
given within eight hours of injury
Given as bolus dose and then IV infusion for 24-48 hours
- 24 hour IVI if treatment commenced within 3 hours of injury
- 48 hours IVI if treatment commenced within 3-8 hours of injury

42. Spinal Trauma: Management
Principles
Early studies (NASCIS I & II)* showed no increased complications
or mortality if 24 or 48 hour IVI
More recent larger studies have raised concerns about increased risk
of sepsis due to immunosuppressive effects
CI: heavily contaminated open injuries, other heavily contaminated
injuries eg perforated bowel, sepsis
Consult with spinal specialist (use or not to use??) More research
needed
Analgesia
* National Acute Spinal Cord Injury Study I & II

43. Spinal Trauma: Management
Principles
Transfer
 Promptly after consultation with spinal specialist
If injury above C6 (can result in partial or complete loss of
respiratory function) – intubate before transfer

44. Secondary Complications
Consider
DVT/PE
Pressure sores
Respiratory complications eg pneumonia UTIs
Muscle length changes
Psychological problems

45. American Spinal Injury Association
(ASIA) Classification
Allows classification of spinal cord injury (standardizing
terminology worldwide)
Based on
- severity of neurological deficit
A=complete to E=normal
- neurological level
most caudal segment with normal function

46. Basic Patient Assessment
Approachevery patient in the samemanner
using 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.

47. Physical Examination
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

48. Clinical presentation
History
•The history of a patient who sustained
spinal injury is usually obvious.
The cardinal symptoms are:
•pain
•loss of function (inability to move)
•sensorimotor deficit
•bowel and bladder dysfunction

49. Spinal Injury: Morphology
Spinal injuries can be described as:
1. Fractures
2. Fracture –dislocations
3. Spinal cord injury without radiographic abnormalities
4. Penetrating injuries
These injuries can be further categorized as stable or unstable

50. Phases of Injury
Primary spinal cord Injury
– initial trauma  direct injury to SC due to fractures,
dislocations, haematomas, soft tissue swelling
Secondary spinal cord injury (later)
– due to ongoing mechanical instability or insults secondary
to hypoxia and hypotension

51. Spinal Injury: Signs and Symptoms
Pain (and bony tenderness on examination)
Tingling, numbness and weakness in peripheries
Loss of sensation or paralysis below level of injury
Impaired breathing – C3/4/5 (diaphragm)
Incontinence
Priapism

52. Spinal Trauma: Primary Survey
Activate trauma team, triage to trauma bay
Move patient off spinal board as soon as clinically safe to do so
Airway maintenance with C spine immobilisation
- definitive airway early if respiratory
compromise
(injury higher than C6 need intubation and ventilation)
- maintain hard collar, sandbag/bolsters and tape
Breathing and Ventilation
- 15L /min oxygen (NRB) + ventilatory support
- monitor RR, respiratory effort, cough

53. Circulation with haemorrhage control
- if hypotension – hypovolaemic vs neurogenic shock
- assume hypovolaemia 1st : search for source blood
loss + replace fluids
- if SC injury: guide fluid replacement with CVP
monitoring (controversial)
- inotropes may be required
- before IDC – perform rectal examination and assess
rectal sphincter tone and sensation
Spinal Trauma: Primary Survey

54. Disability
- GCS /pupils/BSL
- look for paralysis/paresis/priapism/
anal sphincter tone/bulbocavernosus reflex
Exposure/Environment
– keep warm (blankets, bair hugger, fluid warmer)
peripherally vasodilated, unable to regulate temp if injury above
T4
Spinal Trauma: Primary Survey

55. Adjuncts to Primary Survey
Full non invasive monitoring (consider invasive later)
ECG
Trauma Xray series –lateral cervical spine, chest, pelvis
Bedside FAST scan (?sources of bleeding)
NGT
IDC

56. Focused AMPLE Hx
Ask
mechanism?
does your neck or back hurt?
can you feel me touching your fingers and toes? can you
move your hands and feet?
Spinal Trauma: Secondary
Survey

57. The history should include a detailed
assessment of the injury, i.e.:
•type of trauma (high vs. low energy)
•mechanism of injury (compression,
flexion/distraction, hyperextension,
rotation, shear injury)

58. • In patients with neurological deficits, the
history must be detailed regarding:
• time of onset
• course (unchanged, progressive, or
improving)

59. Concomitant Non-spinal Injuries
• one-third of all spine injuries have
concomitant injuries
• Most frequently found concomitant injuries
are:
1.head injuries (26%)
2.chest injuries (24%)
3.long bone injuries (23%)

60. Physical Findings
• The inspection and palpation of the
spine should include the search
for:
• swellings
• Tenderness
• skin bruises, lacerations, ecchymoses
• open wounds
• hematoma
• spinal (mal)alignment

61. Neurological evaluation :
• ASIA form is used to record the neurological
findings
• Neurological deficit of the patient Depends
upon Complete or incomplete injury of the
cord .

62. Neurological Evaluation
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.

64. Grading of Spinal Cord Injury
40

65. Investigations :
• plain X-
rays,
• CT and
• MRI studies
X-RAYS
• A-P &
• Lateral
views

66. CT :
• The axial view allows
an accurate
assessment of the
comminution of the
fracture
• and dislocation of
fragments into the
spinal canal .

67. MRI :
• In the presence of neurological deficits, MRI is
recommended to identify a possible
 cord lesion or a cord compression that may be
due
to
disc or
fracture fragments
or epidural
hematoma

68. • MRI can be helpful
in determining the
integrity of the
posterior
ligamentous
structures and
thereby
differentiate
between a stable
and an unstable
lesion.

70. Take Home Messages
Over half of spinal cord injuries occur in the cervical spine
region (most vulnerable and mobile region)
C spine immobilisation in trauma = spinal board (initially), hard
collar, sandbags/bolster and tape
Consider early intubation and ventilation with injuries higher
than C6 (altered LOC, regurgitation, cervical haematomas) –
hypoxaemia is late sign of deterioration
Follow ATLS ‘A B C D E’ algorithm in spinal trauma –
aim is
to limit secondary spinal cord injury

71. Take Home Messages
Neurogenic shock is a triad of hypotension, bradycardia and
peripheral vasodilation
In trauma patients, neurogenic shock is a diagnosis of
exclusion
Watch over zealous fluid treatment – if hypotension not
improving with fluid resuscitation, consider neurogenic shock
EARLY discussion with spinal specialist the use of
noradrenaline (for hypotension) and steroids (remains
controversial) in spinal trauma

72. Thank you