includes traumatic paraplegic and its ortho mangment

1. TRAUMATIC
PARAPLEGIA
DR.BHARTI PAWAR (MSK PT)

2. INTRODUCTION
 Spinal Cord Injury is an insult to the spinal cord resulting in a change
either temporary or permanent in the cord’s motor,sensory,or autonomic
function.
 The International Standards for Neurological and functional
Classification of Spinal Cord Injury(ISNCSCI)is a widely accepted system
of describing the level and extent of injury which gave the following
terminologies.
 Tetraplegia-injury to the spinal cord in the cervical region with
associated loss of muscle strength in all 4 extremities.
 Paraplegia-Injury to the spinal cord in the thoracic,lumbar or sacral
segments including the cauda equina and conus medullaris.

3. Neural injuries are divided into two broad etiology based categories.
 Primary Injury-Physical tissue disruption caused by mechanical forces.
 Secondary Injury-Additional neural tissue injury resulting from the
biologic response initiated by the physical tissue disruption.
Classification based on the physical Characteristics.
 Concussion-physiologic disruption without anatomic injury.
 Contusion(most common)-physical tissue disruption leading to
hemorrhage and swelling.
 Laceration(very rare)-loss of physical continuity i.e, complete transection
of neural tissue.

4.  Spinal cord injury predominantly occurs in the young males, with a male
to female ratio of 4:1.
 The most common cause of traumatic spinal cord injury is a motor vehicle
crash-42%.
 Falls-27%
 Gunshot injuries-16%.
 Sports injuries-7%.

5.  The most common site of spinal cord injury is the cervical spine-50-64%,
 Followed by lumbar region-20-24% and
 Thoracic cord-17 to 19%.

6. Brief Anatomy of the Spinal Cord
 The spinal cord is divided into 31 segments,each with a pair of
anterior and posterior spinal nerve roots.
 On each side the anterior and dorsal nerve roots combine to form the
spinal nerve as it exits from the vertebral column through the neural
foramina.
 The spinal cord extends from the base of the skull to the lower end of
the L1 vertebral body.
 The spinal cord is organized into a series of tracts or neuropathways
that carry motor and sensory information.

7.  The corticospinal tracts are descending motor pathways which
decussate in the medulla located anteriorly within the spinal cord.
 The dorsal columns are the ascending sensory tracts that transmit
light touch,proprioception,and vibration information to the
sensory cortex.
 The lateral spinothalamic tracts transmit pain and temperature
sensation.
 Sympathetic (thoraco lumbar outflow)exits between the C7 to L1.
 Parasympathetic pathways(Craniosacral outflow) exit between the
S2-S4 segments.

9.  Cervical vertebra-Add 1 to the
vertebral level.
 Upper thoracic vertebrae-Add 2.
 Lower thoracic(T7-T9)-Add 3.
 At D10-L1 & L2.
 At D11-L3 & L4.
 At D12-L5 cord segment.
 At L1-All Sacral segments over.
 Below L1-Cauda Equina.

10. Vascular supply
 It consists of the one anterior and two posterior spinal arteries.
 The anterior spinal artery supplies the anterior two thirds of the spinal
cord.
 It arises from the union of two arteries arising from the vertebral artery.
 Posterior spinal artery,two in no. and arises directly from the terminal
branch of each vertebral artery(posterior inferior cerebellar artery).
 The anterior and posterior arteries are supplemented by the radicular
arteries,the largest of these is the artery of Adamkiewicz which usually
lies on the left side and reinforces the arterial blood supply to the lower
end of the spinal cord.

11. Spinal Cord Injuries Proper
 Complete injury of the spinal cord is defined by the absence of the sensory and
motor function in the lowest sacral segment.
 Sacral sensation refers to the sensation at the anal mucocutaneous junction and
deep anal sensation.
 Sacral motor function is voluntary anal sphincter contraction on digital
examination.
 Incomplete injury have partial preservation of the sensory or motor in the lower
sacral segment.
 For the patient to be sensory incomplete they must demonstrate either sensory
preservation in the S4-S5 or deep anal sensation.
 For the patient to be motor incomplete they must demonstrate either voluntary
anal sphinchter contraction or presence of lower extremity motor function more
than three levels below the designated motor level of injury.

12. Initial assessment and care-
 All trauma patients are at risk for spinal injury.
 Proper extrication of the patient and immobilization of the spine are
critical to avoid further neurological injury.
 Immobilizing the patient in a Kendricks Extrication device is an
effective means in spinal emergencies.
 Other options for immobilization include hard cervical
collar,sandbags,spine board.

15. Logrolling of the patients is an important maneuver in the field transportation
of the patients

16. Emergency room care-
Differences between the neurogenic and hemorrhagic shock should be
identified

17.  The American Spinal Injury Association(ASIA) provides a
useful format for guiding in the assessment of the
neurological injury.

19.  The essential elements in the examination in the neurologic function include
strength assessment of the 5 specific muscles in each limb and pinprick sensation
testing at 28 specific points on each side of the body.
 On each side of the body five muscles representing the segments of the lumbar
cord are score on a 5-point muscle grading scale.The sum of all 20 muscles yields a
total score for each patient with a maximum possible score of 100.

23.  For the 28 sensory dermatomes on each side of the body sensory levels are
scored on a 0-2 scale with a total score of 112.

26. Spinal shock
It was first defined by Whytt in 1750 as a loss of sensation accompanied by
motor paralysis with initial loss but gradual recovery of reflexes, following
a spinal cord injury (SCI).
Reflexes in the spinal cord caudal to the SCI are depressed (hyporeflexia) or
absent (areflexia) while those rostral to the SCI remain unaffected.
It should be distinguished from the neurogenic shock which is characterized
by the hypotension and loss of reflexes below the spinal level of injury.

30. Bladder in Paraplegia
UMN Bladder or Automatic Bladder or
Spastic Bladder.
 Lesion cranial to the S1-S3.
 Detrusor Sphincter Dysynergia.
 Partial voiding(intact local reflex arc).
 Residual volume.
 Difficulty to express.
 Loss of voluntary control.
LMN Bladder or Aitinomous Bladder
or Flaccid Bladder.
 Lesion interupting the reflex
arc(S1-S3).
 Partial emptying of the bladder.
 Residual volume larger than the
UMN bladder.
 Easy to manually express.
 Loss of voluntary control.

33. Diagnostic Modalities.
 1.Plain Xray-AP and Lateral views of the TL and LS
spine should be obtained.

34. Points to be noted in AP View.
 Isolated fractures of the transverse
process.
 Loss of vertebral height.
 Widening of the interpedicular distance.
 Vertebral translation.
 Increased interspinous distance.
 Horizontal split in the body at the level
of pedicles.

35. Points to be noted in lateral view
 Loss of anterior vertebral body
height.
 Kyphosis.
 Spinous process widening.
 Loss of posterior vertebral body
height.
 Translation.
 Spinous process fracture.

36. 2.CT Scan.
Advantages:
 Most accurately depicts bony injuries.
 Sensitivity and specificity > 95% .
 Concomitant multi-slice CT of chest,
abdomen and pelvis can be done to
detect visceral injuries.
 Extent of vertebral body
comminution.
 Retropulsion of bone fragments.
 Lamina fracture.
 Pedicle fracture.

38. Reverse Cortical sign
 The retropulsed fragment that has rotated
more than 180 degrees so that the cortical
surface is opposed to the cancellous surface of
the main vertebral body.
 Severe disruption of the posterior ligamentous
complex
 Due to 180° rotation the fragment will not
unite with the main vertebral body
 Anterior decompression is usually preferred.
 Contraindication for ligamentotaxis.

39. 3.MRI-
Indications:
 Patients with neurological deficit.
 Patients with suspicious PLC injury.
Advantages:
 In patients with neurological deficit, MRI accurately depicts the extent of
cord compression, edema, hemorrhage and the presence of cord
transection.
 Determines extent of injury to posterior ligamentous complex. .
 Helps to identify multi-level non-contiguous injuries.
Disadvantages:
 Cost and availability.
 Delay in definitive management.

40.  Bony compression of spinal cord.
 Hyperintense signal changes in
cord.
 Hyperintense signal in the PLC.
 Marrow edema in adjacent bones.
 Epidural hematoma.
 Cord transection.
 Multilevel injury.

41. Role of Steroids in the Acute Spinal Cord
Injuries

42.  Methylprednisolone is not recommended for the following circumstances.
 The multiply injured patient.
 Penetrating spinal cord injury.
 Patients with glucose intolerance or diabetes mellitus.
 Patients with multiple medical comorbidities or with impaired immune
system.
 Elderly patients.
 Patients with a complete thoracic spinal cord injury

43. Thoracolumbar Injuries in
Brief

44. Denis three column concept of stability.

45. McAfee’s Classification of fractures of
Thoracolumbar spine
 1.Wedge Compression Fractures-isolated failure of
the anterior column and result from forward flexion.
 2.Stable Burst Fractures-anterior and middle
columns fail and there is no loss of integrity of the
posterior elements.
 3.Unstable Burst Fractures-All the three columns are
disrupted.There is a tendency for the posttraumatic
kyposis.

46.  4.Chance fractures-Horizontal avulsion injuries of
the vertebral bodies caused by flexion around an
axis anterior to the ALL.The entire vertebra is
pulled off by the tensile force.
 5.Flexion Compression Fractures-Flexion occurs
at an axis posterior to the ALL.The anterior column
fails in compression whereas the middle and the
posterior columns fail in tension.
 6.Translational Injuries-these are characterized
by the malalignment of the neural canal which has
been totally disrupted.all the three columns fail in
shear.

48. Management of Thoracolumbar injuries
 Stable injuries of the spine can be managed with braces.

49.  The operative decision making is dictated by the
 -Morphology of the fracture.
 -The status of PLC.
 -Neurologic status of the patient.
 -Other medical comorbidities

50. Indirect Decompression
 The indirect approach to decompress the spinal cord by ligamentotaxis is
a technique that utilizes the posterior instrumentation and a distraction
force applied to the intact posterior longitudinal ligament to reduce the
retropulsed bone fragments from the spinal canal by tensioning the
posterior longitudinal ligament.

51.  Ligamentotaxis.

52. Direct Decompression
1.Posterior Approach-
 This is one of the most commonly used approach for the thoracolumbar
injuries.
 Advantages are it reduces the morbidity associated with the anterior
approach like decreasing the operative blood loss,avoids visceral
injury.decreases the operative time.
 Transpedicular screw fixation is the gold standard approach now for the
treatment of thoracolumbar injuries.

54. 2.Closed Reduction
 Primary reduction is performed by positioning of the
patient onto a frame to create lordosis.
3.Pedicle screws.
 Pedicle screws are inserted into the vertebrae
cephalad and caudal to the fracture level on both
sides.
4.Rod contouring
 The contouring of the rod depends on the site of the
fracture following the natural curvature of the
spine.

55. 5.Rod insertion
 The rods are introduced to the distal
screw heads on both sides and tightened.
 The rod is then inserted into the proximal
screw heads without tightening.
6.Decompression
 If it is decided to perform an indirect
decompression, this is done at this stage.
If indirect decompression proves to be
insufficient, a direct decompression eg,
posterior or transpedicular decompression
are undertaken.

57. 2.Anterior approach-
 The indications include:
 The presence of a traumatic disc herniation causing neurologic injury.
 The need to remove a portion or entire vertebral body followed by
reconstruction for stability, or for relief of symptomatic neural
compression
 Ventral epidural hematoma.
 Kyphotic angulation with ventral compression.
 An anterior decompression can be done through a partial or total
corpectomy, both including discectomies above and below the fractured
vertebra.
 If a vertebral body or a disc lesion compresses the spinal cord, it should be
removed with the respective decompression technique.

59. Step 1: Discectomy
 Discectomy always precedes corpectomy, because it allows the surgeon to
visualize the upper and lower limit of the spinal canal.
 For partial corpectomy, discectomy is done for the disc adjacent to the
fractured end plate.
 For a complete corpectomy, discectomy is done both above and below that
fractured vertebra.

61. Step 2 - Corpectomy
 In a second surgical step, a total or a partial corpectomy is undertaken.
 A total corpectomy involves removal of the entire vertebral body and
adjacent discs.
 Partial corpectomy involves removal of fractured ends of vertebral body
and adjacent discs.

62. Step 3- Reconstruction.
1.Total corpectomy
 Anterior reconstruction of the disc space
or vertebral body following a complete
corpectomy can be performed using an
autograft or allograft, strut graft, or a
synthetic or metallic cage (expandable or
non expandable).
 Additional bone grafting can be used from
the corpectomized vertebral body and the
removed rib.

63. 2.Partial corpectomy
 The anterior reconstruction of the
vertebral body is performed using a mesh
or tricortical iliac crest bone graft.
 The bone graft stemming from the
vertebral body is transplanted to bridge
the segment

64. 4 Stabilization
Application of plate instrumentation
 The appropriate size plate is chosen by
using a measuring forceps to
determine plate length.
 A plating template is then applied to
the remaining vertebral bodies to
make sure the plate fits flush on the
bone.
 A drill guide is used to drill holes
within the vertebral body.

65.  Anterior rod screw system
 Another form of anterior instrumentation is using a single rod construct after
placing a strut graft with a bone screw above and below the fusion site. Some
fixation systems are designed to place two rods in parallel to one another to
provide the potential for standalone anterior fixation.

66. Rehabilitation in spinal cord injuries.
 Rehabilitation following SCI is most effectively undertaken with a
multidisciplinary, team-based approach, as follows.
 Physical therapists.
 Occupational therapists.
 Rehabilitation nurses.
 Psychologists.

67. 1.Pressure ulceration(Bed Sores).
Stage I: Non-blanchable erythema.
Stage II: Partial thickness.
Stage III: Full thickness skin loss.
Stage IV: Full thickness tissue loss.

68. 2.Spasticity:
 It is a velocity-dependent increase in muscle tone and occurs commonly
following spinal cord injury.
 Regular muscle stretching and joint range of motion prevents this.
 Oral medication include Baclofen 200mg tid.

69. 3.Thromboembolic disease
 The increased risk of thromboembolism is likely due to venous stasis and
hypercoagulability.
 Pneumatic compression devices can be used for the first 2 weeks.
Unfractionated heparin (5000 U SC every 12 hours) or a low-molecular-weight
heparin (30 mg SC every 12 hours), such as enoxaparin, can be administered
for 2-3 months following injury.

70. 4.Bladder management:
 Acute bladder management is by use of an indwelling catheter, as the bladder is
likely to be flaccid.
 Selection of a bladder drainage method ideally is made following urodynamic
evaluation. Clean intermittent catheterization is a method available to those with
good hand function or to skilled attendants. The patient is instructed to limit fluid
intake, and catheterization is performed every 4-6 hours.
 Reflex voiding into a condom catheter is an option available to men with reflex
bladder contractions. Problems can include urinary retention or high intravesical
voiding pressure due to detrusor-sphincter dyssynergy. Voiding pressure sometimes
can be decreased by alpha-blocking agents such as terazosin or tamsulosin .

71. 5.Bowel Management.
 A typical problem is stool that is too hard because of the prolonged
colonic transport time, which leads to drying of the stool.
 Intervention includes maintenance of adequate intake of fluid and fiber,
with fiber acting as a sponge to hold moisture within the stool. Docusate
sodium (100 mg PO bid) can increase the ease with which water enters the
stool.
 Another problem is incontinence. The goal is to establish a set time for
daily bowel evacuation, ideally after a meal to take advantage of any
gastrocolic reflex.

72. 5.Neuropathic Pain.
 Neuropathic pain following spinal cord injury (SCI) is perceived at or below the
level of injury.
 Anticonvulsants may be particularly useful in cases of lancinating electrical pain.
Gabapentin (initial dose of 100 mg PO tid, gradually titrated upward) typically is
used, with precautions for sedation.
 Tricyclic antidepressants like amitryptiline may be useful for more constant
diffuse pain.

73. 6.Functional Rehabilitation:
With regard to recovery below the level of the lesion, ASIA A patients typically
do not show significant recovery in this area. Individuals who are in ASIA B
have approximately a 31% chance of improving to grade D at 1-year
follow-up, while those with initial grades of C have a 67% likelihood.

74. THANK YOU !