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Spine Trauma
- 2. Anatomy
- 3. Cervical Small vertebral bodies (lesser weight bearing) Extensive joint surfaces allows greater ROM (rot, flex, ext) Thoracic Rib bearing vertebrae Designed to remain stiff (minimal flex, ext) Lumbar Weight-bearing vertebrae, houses cauda equine. (min rot) Sacral Transmits weight of body to the pelvis. (no motion) Anatomy
- 4. Anatomy Spinal nerve roots pass out intervertebral foramen C1-7 exit above C8-L5 exit below Spinal nerve: ventral (motor), dorsal (sensor) Sensoric cells in dorsal Motoric cells in Ventral horn Cauda equina formed by L & S nerve in the spinal canal before exiting
- 5. Mechanism of injury Direct injury Penetrating injuries to the spine, particularly from firearms and knives Indirect injury Most common cause of significant spinal damage Fall from a height spinal column collapses in vertical axis Forces: axial compression, flexion, lateral compression, flexion-rotation, shear, flexion- distraction and extension Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 6. •Motorcycle crashes •Falls • Hangings • Blunt trauma • Penetrating trauma to the head, neck • Gunshot wounds • Any unresponsive trauma patient Suspicious: A Spine Injury?
- 7. Stable vs Unstable Treat as unstable until proven otherwise Stable injuries Vertebral components will not be displaced by normal movements. Little risk of neural damage Unstable injuries There is a significant risk of displacement and consequent damage – or further damage – to the neural tissues Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 8. Clinical Evaluation Injuries of the vertebral column tend to cluster at the junctional areas: Craniocervical junction (occiput to C2) Cervicothoracic junction (C7-T1) Thoracolumbar junction (T11-L2). Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 9. Diagnosis KEY POINTS: Every patient with a blunt injury above the clavicle, a head injury or loss of consciousness should be considered to have a cervical spine injury until proven otherwise Every patient who is involved in a fall from a height or a high- speed deceleration accident should similarly be considered to have a thoracolumbar injury Consider the presence of a vertebral column injury in all patients with multiple injuries Lesser injuries also should arouse suspicion if they are followed by pain in the neck or back or neurological symptoms in the limbs Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 10. Signs & Symptoms Suggestive of Spine Trauma • Respiratory distress • Tenderness at the site of injury on spinal column • Pain along the spinal column with movement • Deformity of the spine (rare) • Numbness, weakness or tingling in the arms or legs • Loss of sensation or paralysis in the upper or lower extremity • Incontinence or loss of bowel or bladder control Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 11. A general physical examination is done with the patient supine ABC! Spinal shock & neurogenic shock Neurogenic shock Peripheral vessels dilate hypotension, but the heart doesn’t respond by increasing its rate Paralysis, warm and well-perfused peripheral areas, bradycardia and hypotension with a low diastolic blood pressure. Spinal shock occurs when the spinal cord fails temporarily following injury Below the level of the injury, the muscles are flaccid, the reflexes absent and sensation is lost Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 12. Diagnosis : physical exam Head Head: laceration, contusion, and palpate for facial fracture Ear canal: inspect to rule out leakage of spinal fluid or blood The spinous processes should be palpated from the upper cervical to the lumbosacral region. A painful spinous process may indicate a spinal injury Neck Any complaint of pain or tenderness indicative of a spinal injury collar immobilization Neck motion only after the patient reports no pain or tenderness during examination of the neck An assistant should hold the neck steady in a neutral position Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 13. Diagnosis : physical exam Sensory examination: Sensation to light touch Pinprick sensibility Motor strength Physiological and pathological reflexes Motor and sensory evaluation of the rectum and perirectal area Incontinence of the bowel or bladder suggest a significant spinal injury Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 14. Diagnosis : physical exam Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 15. Sacral Sparing Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral- sparing. Complete - Absence of sensory and motor functions in the lowest sacral segments Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7th edition. 2010
- 16. Evaluating Sacral Sparing Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral- sparing. Sacral sparing may include the triad of perianal sensation, rectal tone, and great toe flexion Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7th edition. 2010
- 17. Imaging X-ray examination (in secondary survey) of the spine is mandatory for: All accident victims complaining of pain or stiffness in the neck or back or peripheral paraesthesiae All patients with head injuries or severe facial injuries Patients with rib fractures or severe seat-belt bruising Severe pelvic or abdominal injuries Accident victims who are unconscious Elderly people Patients with known vertebral pathology (e.g. ankylosing spondylitis)
- 18. Imaging Minimum of movement and manipulation Apart from AP and lateral views: Open-mouth views: C1 and C2 CT structural damage of individual vertebrae and displacement of bone fragments into the vertebral canal MRI IV discs, ligamentum flavum and neural structures indicated for all patients with neurological signs and those who are considered for surgery
- 19. Compression Fracture Subtypes of compression fractures: Type A: Fracture of both endplates Type B: Fracture of superior endplate Type C: Fracture of inferior endplate Type D: Both endplates intact
- 20. Burst Fracture •Type A Fracture of both end- plates •Type B Fracture of the superior end-plate •Type C Fracture of the inferior end-plate •Type D Burst rotation •Type E Burst lateral flexion
- 23. Classification of Neurological Function Sensory Motor A Absent Absent B Present Absent C Present Active but not useful (grade 2-3) D Present Active and useful (grade 4) E Normal Normal Frankel Classification Grading System
- 24. ASIA Impairment Scale ASIA Grade Clinical state (below level of injury) A Complete Complete: no sensory or motor function preserved in sacral segments S4 – S5 B Sensory incomplete Incomplete: sensory, but no motor function in sacral segments C Motor incomplete Incomplete: motor function preserved below level and power graded < 3 D Motor incomplete Incomplete: motor function preserved below level and power graded 3 or more E Normal Normal: sensory and motor function normal
- 28. Principles of Diagnosis and Initial Management Early management ABCD then assessment of spinal injury The spine immobilized until the patient has been resuscitated and other life-threatening injuries have been identified and treated Immobilization is abandoned only when spinal injury has been excluded by clinical and radiological assessment Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 29. Initial Temporary Immobilization Quadruple immobilization Backboard, sandbags, forehead tape, semirigid collar Scoop stretcher, spine board, log-roll Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 30. Corticosteroid National Acute Spinal Cord Injury Study I, II, and III Protocols Methylprednisolone bolus 30mg/kg infusion 5.4mg/kg/h Infusion for 24h if bolus given within 3 hours of injury Infusion for 48h if bolus given within 3-8 hours after injury No benefit if >8h > 8 hr the consensus is clear that there is no indication for steroid use Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7th edition. 2010
- 31. Principles of definitive treatment The objectives of treatment: To preserve neurological function; To minimize a perceived threat of neurological compression; To stabilize the spine; To rehabilitate the patient. The indications for urgent surgical stabilization are: An unstable fracture with progressive neurological deficit and/or MRI signs of likely further neurological deterioration Controversially an unstable fracture in a patient with multiple injuries Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010
- 32. Non-surgical Closed treatment remains the standard of care for most spinal injuries Bedrest, halo apparatus, external orthosis, cast
- 33. Surgical The only consistent indication for surgical treatment skeletal disruption in the presence of a progressive neurological deficit. Unstable injuries
- 34. Thank you
Editor's Notes
- LEVEL CORRESPONDING STRUCTURE C2-3 Mandible C3 Hyoid cartilage C4-5 Thyroid cartilage C6 Cricoid cartilage C7 Vertebral prominence T3 Spine of scapula T7 Xiphoid, tip of scapula T10 Umbilicus L1 End of spinal cord L3 Aorta bifurcation L4 Iliac creast
- COMPRESSION FRACTURE: It is a failure under compression of the 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. Competent middle column prevents the fracture from subluxation or compression of the neural elements by retropulsion of the fragments of the posterior wall into the canal. Four subtypes of compression fractures can be identified: Type A - involvement of both end plates Type B - involvement of superior end plate Type C - inferior end plate Type D - buckling of anterior cortex w/ both end plates intact.
- BURST FRACTURE: The burst fracture results from failure under axial load of both the anterior and the middle columns originating at the level of one or both end-plates of the same vertebra. Five different types of burst fractures can be described (see the picture below). Type A: Fracture of both end-plates. The bone is retropulsed into the canal. Type B: Fracture of the superior end-plate. It is common and occurs due to a combination of axial load with flexion. Type C: Fracture of the inferior end-plate. Type D: Burst rotation. This fracture could be misdiagnosed as a fracture-dislocation. The he mechanism of this injury is a combination of axial load and rotation. Type E: Burst lateral flexion. This type of fracture differs from the lateral compression fracture in that it presents an increase of the interpediculate distance on anteroposterior roentgenogram.