spine fracture

1. Vertebral Fracture
and
Spinal Cord Injury
HAFIZ ILMIE
FATIMAH ALIA
BAIHAQI
CHE JAUHARAH
ANIS SHAHIDA

2. ANATOMY OF VERTEBRAL COLUMN
Consist of :
• 7 cervical vertebrae: neck region
• 12 thoracic vertebrae: posterior to the thoracic cavity
• 5 lumbar vertebrae: support the lower back
• 5 fused sacral vertebrae: sacrum
• 4 fused coccygeal vertebrae: coccyx

4. TYPICAL VERTEBRA

5. CERVICAL VERTEBRA
C1 (Atlas) C2 (Axis)
•Ring shaped
•2 lateral masses with facets
•2 arches connect lateral masses : ant
& post tubercle
•Transverse process has a foramen
•Lacks a body and a spinous process
• Parts: Body, the dens /odontoid
process
•The articulation formed between the
anterior arch of the atlas and dens
and between their articular facets, is
called the atlanto-axial joint

6. Characteristics Cervical Thoracic Lumbar
Vertebral body Small, oval, curved
faces
Medium, heart
shaped
Largest
Vertebral
foramen
Large Smaller Smallest
Spinous process Long, split tip,
points inferiorly
Long, not split,
project inferiorly
Blunt, broad,
project posteriorly
Transverse
process
Have transverse
foramina
All but 2 have facets
for rib articulations
Short, no articular
facets or transverse
foramina
Articular facet
for ribs
Absent Present Absent

7. Sacrum Coccyx
•Triangular, formed by the union of five
sacral vertebrae (S1–S5)
•Articulates with L5 & coccyx
•Has 2 large L shaped facets (on lateral
surface) for articulation with pelvic bones
• Triangular, formed by the fusion of four
coccygeal vertebrae
• The dorsal surface of the body of the
coccyx : coccygeal cornua that are
connected by ligaments to the sacral cornua
• Lateral surfaces: transverse processes
• Articulates superiorly with the apex of the
sacrum

8. FUNCTION
1. Strong, flexible rod that can move forward, backward, sideways,
and rotate - Allow movement
2. Supports the body weight
3. Serves as a point of attachment for the ribs, pelvic girdle, and
muscles of the back and upper limbs.
4. To enclose and protect the spinal cord & nerve roots.

9. CLINICAL PRESENTATION
Lumbar Vertebral Fracture
• Moderate to severe back pain, worsening by movement.
• Spinal cord involvement :
- bowel/bladder dysfunction
- Numbness/ tingling sensation
- Weakness in the limbs
• High energy trauma : brain injury, loss of consciousness.

10. EMERGENCY
MANAGEMENT

11. Emergency Management
1. Initial assessment and stabilization
 ABC algorithm
 Rapid assessment and treat life treatening injuries
2. Secondary survey
 Look for other associated injuries (brain injury, thoracic injury, abdominal injury).
 Might do neurological examination to determine any presence of neurological
deficit.
3. Immobilization
 To avoid injuries during transport and prehospital phase.

12. METHODS OF TEMPORARY IMMOBILIZATION
• Cervical spine – use in line immobilization, head & neck supported in neutral
position.
• Quadruple immobilization
- applied backboard, sandbags, forehead tape, semi-rigid collar.
• Thoracolumbar spine
- scoop stretcher & spinal board
- log rolling technique

13. Scoop stretcher
Spinal board
Log-rolling technique

14. DENNIS THREE COLUMN
1. To assess the spinal stability
2. Particularly useful in assessing the stability of lumbar injuries
3. 3 structural elements must be considered
• posterior column
• middle column
• anterior column

16. STABLE INJURY UNSTABLE INJURY
• The vertebral components will
not be displaced by normal
movements
• Significant risk of displacement
and consequent damage
• Little risk of neural elements
becoming damaged
• May cause further damage to
the neural tissues

17. Lumbar Vertebral Column
Fractures
FATIMAH

18. Wedge compression
Burst
Flexion-distration
Fracture-dislocation

19. Wedge compression
• Flexion-compression injury
• Most common vertebral fracture
• Due to severe spinal flexion

20. • Osteoporotic individuals fracture may occur with minimal trauma

21. Clinical Presentations
• Pain – localized
• Focal tenderness
• Local kyphosis in multiple compression fracture
• Nerve root deficit – pain, weakness, tingling, numbness

22. • Posterior ligaments remain intact
• Fracture usually stable
• Neurological injury is rare

24. Treatment
Minimal wedging & a stable
fracture
Bed rest (1/ 2 weeks) until pain subsides
Then mobilized; no support is needed.
Moderate wedging (loss of 20–
40 % of anterior vertebral
height) & a stable injury
Wearing a thoracolumbar brace or a body cast
applied with the back in extension. (can be
allowed up after a week)
Loss of anterior vertebral height
is greater than 40 %
surgical correction & internal fixation is the
preferred treatment.
Wedge compression fracture and
neurological impairment
Operative decompression & stabilization through
a trans-thoracic approach.
Complete paraplegia with no
improvement after 48 hours
Conservative management is
• Bed rest for 5–6 weeks
• gradually mobilized in a brace.
Increasing kyphosis - internal fixation

25. Burst injury
• Severe axial compression
• Lead to damage of both the
anterior and the middle columns.
• The posterior column undamaged.
• Bone fragments and disc may be
displaced into the spinal canal
• Unstable fracture

28. Dennis Classification

29. Treatment

31. Flexion-distraction
• Jack-knife injury
• Common in lap seat-belt injuries
• Anterior column fails under compression
• Posterior and middle column fail under tension

32. • Usually patient is neurologically intact
• Associated with intra abdominal injury
• Unstable fracture

33. Lateral view: widening of L1 disk
space, perching of facet L1 on L2
AP view: apparent height of the
vertebral body may be increase

35. Treatment
• Bony fracture: 3 months body cast or well-fitting brace
• Ligamentous injury : Posterior spinal fusion

36. Fracture-dislocation
• Segmental displacement occur with various combinations of flexion,
compression, rotation and shear.
• 3 columns involved
• Unstable injury
• Often associated with neurological damage to the lowermost part of
the cord / cauda equina
• Common- thoracolumbar junction

37. • X-rays : fractures through the vertebral body, pedicles, articular
processes and laminae; there may be varying degrees of subluxation
or even bilateral facet dislocation
• CT scan : shows a degree of spinal canal occlusion

38. Fracture dislocation of
L1 over L2

39. Treatment
Fracture-dislocation with paraplegia - Non-operatively by postural
reduction, bed rest and bracing
Fracture-dislocation with partial
neurological deficit
- Surgical decompression and
stabilization (no evidence operative
management > conservative)
Fracture-dislocation without
neurological deficit
- Surgical stabilization
- Rehabilitation

40. Type of
fracture/involvement
Anterior
column
Middle
column
Posterior
column
Unstable/ Stable
Wedge compression
√ - -
Stable
Burst fracture
√ √ -
Stable/unstable
Fracture distraction
- √ √
Stable
Fracture dislocation
√ √ √
Unstable

41. SPINAL CORD INJURY
An insult to the spinal cord resulting in a change, either temporary
or permanent, in its normal motor, sensory or autonomic function
BAIHAQI

42. Functional Anatomy
• Vertebrae: 7C, 12T, 5L, 5S
• Nerve Roots: 8C, 12T, 5L, 5S
• Dermatomes/Myotomes
• Reflexes
• Blood Supply

45. Pathophysiology
Traumatic Non-traumatic
• MVA
• Falls
• Occupational or sport injuries
• Gun shot wound
• Spondylotic myelopathy
• Infectious and inflammatory
diseases
• Neoplastic diseases
• Vascular disorders
• Congenital and development
disorders
• Toxic and metabolic condition

46. Classification

47. complete Incomplete
•an injury with no spared motor or
sensory function below the affected
level.
•patients must have recovered from
spinal shock (bulbocavernosus reflex
is intact) before an injury can be
determined as complete
•classified as an ASIA A
•an injury with some preserved motor
or sensory function below the injury
level
•incomplete spinal cord injuries
include
• anterior cord syndrome
• Brown-Sequard syndrome
• central cord syndrome
• posterior cord syndrome
• conus medullaris syndromes
• cauda equina syndrome

48. Consequences
1. Motor disturbance
- paralysis, atrophy
2. Sensory disturbance
- loss, diminished,
hyperesthesia,
- pain
3. Change of reflex/tone
hypo-, hyperreflexia,
spasticity
4. Autonomic disturbances
- bladder & bowel
dysfunction
- loss of thermoregulation
- erectile dysfunction

49. Central Cord
Syndrome
most common & good
prognosis
MECHANISM OF INJURY
• Cervical hyperextension
injury → spinal cord
compression and central
cord edema
SYMPTOMS
• Bilateral motor weakness
(upper > lower)
• Hyperpathia (burning
sensation)
• bladder symptoms (urinary
retention) may also occur.

50. Anterior Cord
Syndrome
worst prognosis of
all incomplete cord injury
(mimic complete sci)
MECHANISM OF INJURY
• Flexion/Compression injury
→ direct
compression/anterior spinal
artery injury
SYMPTOMS
• Motor paralysis
• Loss of pain & temperature
sensation
• Preserved proprioception,
touch & vibration sensation

51. excellent prognosis
MECHANISM OF
INJURY
• Penetrating injury →
Cord hemitransection
SYMPTOMS
• Hemiparaplegia
ipsilaterally
• Hemianaesthesia
contralaterally
Brown-Sequard
Syndrome

52. very rare
SYMPTOMS
• Only deep pressure &
proprioception are lost
Posterior Cord
Syndrome

53. Cauda Equina Syndrome
SYMPTOMS
• back pain, leg pain
(bilaterally or unilateral)
• saddle anesthesia
• impotence
• sensorimotor loss in lower
extremity
• neurogenic bladder
dysfunction – urinary
retention, overflow
incontinence
• bowel dysfunction is rare
a constellation of symptoms that result from terminal spinal nerve
root compression in the lumbosacral region(roots- l1 to l5, s1 to
s5)(vertebrae below l2)

54. Acute Phase Conditions
1. Spinal shock injury
2. Neurogenic shock

55. SPINAL SHOCK
Transient physiologic reflex depression of cord function below the
level of injury
MECHANISM: neurons become hyperpolarized and unresponsive to
stimuli from brain
SYMPTOMS
• Flaccid muscle
• Absent reflex
• Loss of sensation
• Bradycardia & hypotension (due to loss of sympathetic tone)
DURATION: Rarely lasts for more than 48 hours
ASSESSMENT: Return of the bulbocavernosus reflex (BCR) marks
the end of ‘spinal shock’

56. • These changes consist of three main phases:
1. Reduction of reflex activity results from decreased excitability of spinal
motor neurons
2. Resumption of reflex activity or voluntary movement is attributed to
denervation hypersensitivity
3. Hyperreflexia occurs due to new synaptic growth.
4. Consequently, the motor neuron below the level of injury is predominantly
under either voluntary or reflex control.
5. As a result, various levels of spasticity develop or, in case of an
incomplete lesion, voluntary movement might be recovered, depending on
the extent of spinal cord injury.

58. NEUROGENIC SHOCK
Characterized by hypotension & relative bradycardia in patient with an
acute spinal cord injury & potentially fatal
MECHANISM:
• circulatory collapse from loss of sympathetic tone
RESULT:
disruption of autonomic pathway within the spinal cord leads to
• lack of sympathetic tone Bradycardia
• decreased systemic vascular resistance  vasodilation  pooling of
blood in extremities  dry & warm extremities
• Hypotension  decreased blood Pa

59. Spinal Shock Neurogenic Shock
BP Hypotension Hypotension
Pulse Bradycardia Bradycardia
Reflexes / Bulbocavernosus
Reflex
Absent
Variable/independent
Motor Flaccid Paralysis
Variable/independent
Time
~48-72 hours immediately after spinal cord injury
~48-72 hours immediately after spinal cord injury
Mechanism
Peripheral neurons become temporarily unresponsive to
brain stimuli. Disruption of autonomic pathway leads to loss of
sympathetic tone and decreased systemic
vascular resistance.

60. ASIA Classification
JAUHARAH

61. ASIA CHART
• To define and describe the extent and severity of patient’s spinal cord
injury.
• To document sensory and motor impairment following spinal cord
injury.
• Help determine future rehabilitation and recovery need.

63. 1. Determine sensory levels for right and left
sides.
• Use the score 0, 1 and 2 for each dermatome. Labeled
as NT(not testable) if cannot be tested.
• Score as below:
• 0: no sensation
• 1: sensation present but impaired
• 2: normal sensation
• Pin prick and light touch sensation.
• The sensory level is the last level that have normal
sensation for both pin prick and light touch
sensation.

66. 2. Determine motor levels for right and left
sides.
• The motor level is the lowest key muscle function that has a grade of
at least 3 (on supine testing), providing the key muscle functions
represented by segments above that level are judged to be intact
(graded as a 5).
• In regions where there is no myotome to test, the motor level is
presumed to be the same as the sensory level, if testable motor
function above that level is also normal.

67. • 0 Total paralysis
• 1 – Palpable or visible contraction
• 2 – Active movement, full range of motion, gravity
eliminated
• 3 – Active movement, full range of motion, against
gravity
• 4 – Active movement, full range of motion, against
gravity and provides some resistance
• 5 – Active movement, full range of motion, against
gravity and provides normal resistance
• NT – not testable.

69. 3. Determine the neurological level of injury
(NLI).
• The most caudal segment of the cord with intact sensation and
antigravity (3 or more) muscle function strength, provided that there
is normal (intact) sensory and motor function rostrally respectively.

71. 4. Determine whether the injury is complete
or incomplete.
• Complete (absence sacral sparing).
• If voluntary anal contraction = No
• AND all S4-5 sensory scores = 0
• AND deep anal pressure = No,
• Incomplete (presence sacral sparing).

72. Do per-rectal examination
to determine:
- Anal contraction
- Deep anal pressure

73. 5. Determine ASIA impairment scale (AIS)
grade.
Is injury
complete?
AIS=A
Is injury
motor
complete
AIS=B
Are at least half
of the key
muscles below
the
neurological
level of injury
graded 3 or
better?
AIS=C
AIS=D
If sensation and motor function is
normal in all segments, AIS=E.
YES
YES
YES
NO
NO NO

74. • A = Complete.
• B = Sensory sparing only.
• Sensory but not motor is preserved below the neurological
level and includes the sacral segment S4-5.
• C = Motor Incomplete.
• Less than half of key muscle functions below the single NLI
have a muscle grade ≥ 3.
• D = Motor Incomplete.
• At least half of key muscle functions below the single NLI
having a muscle grade ≥ 3.
• E = Normal.

75. ANSWER
CASE 1
• sensory: R C7, L C6
• motor: R C7, L C7
• neuro: C6
• incomplete
• C6 ASIA C

76. ANSWER
CASE 2
• sensory: R T12, L T11
• motor: R T12, L T11
• neuro: T11
• complete
• T11 ASIA A

77. ANSWER
CASE 3
• sensory: R L1, L L2
• motor: R L1, L L1
• neuro: L1
• incomplete
• L1 ASIA B

78. ANSWER
CASE 4
• sensory: R C5, L S5
• motor: R C6, L T1
• neuro: C5
• incomplete
• C5 ASIA D

79. Complication of Spinal Cord Injury
• Pressure ulcer
• Urinary tract infection
• Autonomic dysreflexia
• Orthostatic hypotension
• Deep Vein Thrombosis
• Pulmonary embolism
• Neurogenic bladder dysfunction
• Gastrointestinal dysfunction
• Neuropathic pain
• Heterotopic ossification
• Impaired sexual function/ Fertility
• Depression

80. CONUS MEDULARIS AND
CAUDA EQUINA INJURY
ANIS

81. ANATOMY

82. As the segments of the spinal cord are left above the
respective vertebra, when a particular vertebra is
injured, it will give rise to injury of segment of the spinal
cord near to it, which is lower than the numerically
corresponding segment.*****
Clinically, it is important to know the segment of spinal cord
likely to be affected in vertebral injury.
Rough guide to estimate it *****:
Vertebra: Add : Spinal Segment
Lower cervical: C5 : +1 : C6
Upper thorax: T4 : +2 : T6
Lower thorax: T9 : +3 : T12.
To estimate a vertebra and segment of the
spinal cord related*****

83. Cauda equina
Cauda equina occupies the vertebral
canal below the level of the conus
medularis of the spinal cord.
It is made up of:***
• filum terminale,
• roots of spinal nerves
from both sides of:
L2 to L5,
S1 to S5 and
Cox 1 .

84. AETIOLOGY
• Narrowing of the spinal canal can be due to a developmental abnormality or
degenerative process
• spinal disorders such as ankylosing spondylitis, spondylosis, and
spondylolisthesis
Spinal stenosis
• fracture or subluxation
• Penetrating trauma
Spinal trauma
• - 90% at L4-L5 or L5-S1.
• MOST COMMON CAUSE OF CES
Herniated disc

85. • primary or metastatic spinal neoplasms
• ependymoma, schwannoma, and paraganglioma.
• Lung, breast, renal, colorectal, lymphtic
Neoplasm
• Paget disease and ankylosing spondylitis
• epidural abscess
• Pyogenic and non pyogenic
Inflammation
and infection
• spinal instrumentation (misplaced pedicle screws and laminar
hooks)
• Continuous spinal anesthesia
Iatrogenic
causes

86. CONUS MEDULLARIS
SYNDROME (CMS)
• Caused by an injury or insult to
the conus medullaris and lumbar
and sacral nerve roots
• Injuries at the level of T12-L2 and
(S1-S5)
• PATHOLOGY
- conus medullaris is part of spinal
cord lies in close proximity to
nerve roots  combined UMNL &
LMNL
CLINICAL PRESENTATION
• saddle anaesthesia (S3-S5)
• loss of bladder reflex: urinary
retention
• loss of bowel reflex: incontinence
• lower limb motor weakness,
paraesthesia and numbness
• Bilateral leg pain

87. PHYSICAL EXAMINATION
• Inspection → lower extremity muscle atrophy
• Palpation → palpation of the bladder for urinary retention
• Neurovascular → bilateral lower extremity weakness, sensory
disturbances, decreased/absent lower extremity reflexes
• Rectal / genital → ↓rectal tone voluntary contracture
• Reflexes of anal and bulbocavernous absent

89. CAUDA EQUINA SYNDROME (CES)
• defined by a constellation of
symptoms that result from
terminal spinal nerve root
compression in the lumbosacral
region
• few true medical emergencies in
orthopaedics
• compression cause LMNL

94. Investigation
 Lab -> FBC, ESR
Plain XRay
 MRI -> accurate, specific, to
investigate underlying causes,
urgent in pt with urinary
symptoms or sciatica
LP -> CSF
CT and myelograph -> good
accuracy

95. METHOD OF DECOMPRESSION
• surgical decompression as soon as possible becomes mandatory
GOALS
• To relieve the pressure on the nerves
• Increase space of the spinal canal
• Preserve neurological function
• Restore alignment of spine
• Rehabilitate patient

96. NON-SURGICAL METHODS
• Analgesics
• Steroid
• Anti-coagulant
• Antispasticity medications eg: baclofen, dantrolene
• Physiotherapy: restore muscle strength and balance, improve blood
circulation to lower extremities
• Non phmco – rehab
• Phmc – analgesic, antispaciticity, baclofen, dantrolene

97. SURGICAL METHODS
• CES has been considered a
surgical emergency, with surgical
decompression considered
necessary within 48 hours after
the onset of symptoms
Indications
• significant suspicion for CES
• severity of symptoms will
increase the urgency of surgical
decompression
Techniques
• Discectomy- surgical removal of
herniated disc material that
presses on a nerve root or the
spinal cord.
• Laminectomy- surgery that
creates space by removing the
lamina - the back part of the
vertebra that covers the spinal
canal.