TRAUMA MEDULA

SPINALIS
Dr. Rendra leonas SpOT
ORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY
MOH. HOESIN PALEMBANG

Introduction
Most common
age and high speed level
traffic accident >>
80% spinal inj not assoc SI
more important preliminary
care

At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.

Anatomy and Physiology

33 bones comprise the spine

Function
Skeletal support structure
Major portion of axial skeleton
Protective container for
spinal cord

Vertebral Body
Major weight-bearing
component
Anterior to other
vertebrae components

Anatomy and Physiology

SPINAL NERVES
31 pairs of spinal nerves :

8 cervical
12 thoracic
5 lumbar
5 saccral
1 coccygeal

Each has both motor and sensory

fibers
Motor fibers = anterior or ventral root
Sensory fibers = posterior or dorsal root

Anatomy and Physiology

Components of
Vertebrae
Spinal Canal
Opening in the
vertebrae that the
spinal cord passes
through

Pedicles
Thick, bony structures
that connect the
vertebral body to the
spinous and transverse
processes

Anatomy
Spinal cord ends below lower border of L1
Cauda equina is below L1
Mid dorsal spinal cord & neural canal space are of
same diameter hence prone for complete lesion
Mechanical injury - early ischaemia, cord edema cord necrosis
Neurological recovery unpredictable in cauda equina
ie. peripheral nerves

OVERVIEW
LOOK
inspection

FEEL
palpation

MOVE
active & passive
movements

EXAMINATION :STANDING

Feel :
Tenderness: may be bony,

intervertebral or paravertebral
Bony prominence or steps
spinous processes
using C7 &/or L4-5
as landmarks

facet joints
approx. 2cm lateral to spinous processes

EXAMINATION : STANDING

Feel :
assess alignment, mobility &
tenderness of:
transverse processes of
vertebrae
lateral to spinous processes

Signs of nerve root

compression
Standard full neurological
examination of both lower limbs :
tone, power (MRC grading)
sensation (light touch, pinprick &
proprioceptive if indicated)
reflexes (physiologic and patologic)
an anatomical distribution
[dermatome(s) or myotome(s)]

Neurological Examination
Objectives :
Determine if defect is present
Localize the level of the deficit

Include :
Sensory
Motor
Reflex

Neurological Examination
Sensory examination
Explain, eyes closed
Examine : touch, 2 point
discrimination, proprioceptive.
Sensory dermatomes, compare each
opposite

Sensory Dermatome

Muscle Power Grading

0 - complete paralysis
1 - flicker of contraction possible
2 - movement is possible when gravity is
excluded
3 - movement is possible against gravity
4 - movement is possible against gravity +
some resistance
5 - normal power

Neurological Examination
Motor
examination
Muscle grading
Compare each side

Cervical
:
Scapular

C4

Deltoid & Biceps

C5

Wrist extension & supination

C6

Wrist flexion & Pronation

C7

Neurological Examination
Motor
examination
Lumbo-sacral
Hip flexor
Hip extensor

L 1,2,3
S1

Knee flexor
Knee extensor

L 4,5, S1,2
L 2,3,4

Ankle flexor
Ankle extensor

S1
L5

Denis 3 Column Theory

Denis, F.: The Three-Column Spine and its Significance in the

Classification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)

Cervical spine anatomy

Anterior column - Anterior longitudinal ligament+
Anterior annular ligament and anterior half of VB.
Middle column Posterior long. Lig. + Posterior
annular ligament +Posterior half of VB.
Posterior Column Lig flavum + superior &
Interspinous lig + intertransverse capsular lig + neural
arch + pedicle & spinous process.

Basic Types of Spine Fractures

1. Compression
fracture
2. Burst fracture

Denis
Classification

Basic Types of Spine Fractures

3. Seat-belt injury (Flexion-distraction
injury)

Bony Chance fracture

Soft tissue Chance injury

Basic Types of Spine Fractures

4. Fracture-dislocation

Anterior posterior shear

Flexion-rotation

Flexion-distraction

Classification spine
fracture
Stable injury
fracture

compression
burst fracture

Unstable injury : dislocation

fracture dislocation
chance fracture

Classification spine fracture

Location :
1. Jefferson fracture
2. Dens fracture
3. Hangmans fracture
4. Clay shovelers fracture
5. SCIWORA

Compression fracture

Failure of the anterior column

Mechanism anterior or lateral flexion
Normally Stable or unstable fracture
Rarely involved neurologic
comprimise

Criteria unstable
Loss of 50% of vert body height
Angulation of thoracolumbar junct >
20 deg
Mutiple adjacent column of spine
Failure of 2/3 of column of spine

Chance fracture
Anterior column falls in tension
(along w/ the middle and posterior
columns)
Three columns rupture in distraction
(tension)
Seldom assc w/ neurologic
comprimise unless
Unstable

Burst fracture
Compressive failure of vert body both
anteriorly & posteriorly , w/ failure of
both anterior & middle columns
Axial loading applied to
intravertebral disc results in
increased nuclear pressure and hoop
stresses in the annulus

Burst frx location

Cervical burst fix
Lumbar burst fix
Thoracic burst fix
Thoracolumbar burst fix

Classification :
Stable frx
- neurologically intact
- poterior arch remains intact : pedicl
widening implies post arch
disruption
- less than 50% anterior body height
- compression fracture

 Unstable frx
- neurologic defisit
- loss of 50% vertebral body height
- fracture dislocation
- thoracolumbar burst frx

Jefferson Fracture
Pediatric frx
- frx proceeds thru open
synchondroses,
and may occur w/ minimal trauma/
- posterior synchondroses fuses at
age 4
- anterior synchondroses fuses at age
7

 Mechanism
- original description in 1920 noted
role of
axial compression
- may also be caused by
hyperextension,
causing a posterior arch fracture

 Associated injuries
- approx 1/3 of these fractures are
associated with a axis fracture
- approx 50% chance that some
other
C-spine injury is present
- low rate of neurologic deficits is due
to
large breadth of C1 canal

Radiographs
Odontoid view
Lateral view
Flexion and extension views
CT scan

Dens Fracture
Odontoid fractures are the most
common upper cervical spine
fratures
Remember rule of thirds cervical
cord occupies a 1/3 of canal, dens
occupies a 1/3 and the remaining 1/3
is empty
Mechanism
Flexion loading
Extension loading

Classification
Type I
Type 2 Dens frx
Type 3

Associated Injury
Atlas frx
Transverse ligament rupture
Pharangeal injury

Hangmans frx/Traumatic
Spondylolisthesis of the Axis
Fix of pars interarticularis of C2 & disruption of
C2-C3 junction
Type of traumatic spondylolisthesis Hangmans
frx
Term Hangmans fracture is not accurate for the
majority of cases, because mechanism of injury
for clinically encountered frx often lacks large
traction force present in judicial hangings

 In cases in which there is neurologic

injury, there will usually be
significant horizontal translation w/
accompanying damage to the
posterior longitudinal ligament w/ or
w/o damage of the C2 C3
interspace

 Mechanism of injury in adults

Judical lesion : hyperextension and
distraction
Hyperextension w/ vertical compression
of posterior column, & translation of C2
and C3
Forceful extension of already extended
neck is most commonly described mech
of injury, but other causes include
flexion of flexed neck & compression of
an extended neck
A blow on the forehead forcing the neck
into extension is a classic mechanism of
injury producing fractures thru the

SCIWORA Syndrome
Occurs may often in pediatric
population
Accounts for up to 2/3 of severe
cervical injuries in children < 8 years
of age
Inherent elasticity in pediatric
cervical spine can allow severe spinal
cord injury to occur in absence of xray findings

Clasification spinal cord

injury

Complete
Incomplete
Anterior cord syndrome
Central cord syndrome
Brown sequad
Cauda equina

Anatomy
crossection spinal cord
Ascending
Tract
Tracts of Goll and
Burdach (fasc gracilis
and cuneatus

Proprioception,vibration
,discrimination

uncrosssed

Dorsal and ventral

spinocerebellar tract

Proprioception, light
touch

uncrossed

Lateral spinothalamic
tract

Pain, temperature

crossed

Spinal olivary tract

Tendon and muscle

proprioception

crossed

Ventral spinothalamic
tract

Deep tactile and

pressure sensation

crossed

Lateral corticospinal tract

(pyramidal)

Motor control

uncrossed

Rubrospinal tract

Cerebellar reflexes

crossed

Lateral reticulospinal
Vestibulospinal
tracttract

Inhibits
locomotor
Postural
control conytrol

crossed
Uncrossed

Reticulospinal tract
Tectospinal tract

Facilittes locomotor control

Eye and ear reflleces

uncrossed
crossed

Descending
Tract

Complete / incomplete Spinal Cord

Lession
Complete cord injury : there is complete
loss of sensation and muscle function in
the body below the level of the injury
An injury to the upper portion of the spinal
cord in the neck can cause quadriplegiaparalysis of both arms and both legs. If the
injury to the spinal cord occurs lower in
the back it can cause paraplegiaparalysis of both legs only.

 Incomplete lesion : there is some

remaining function below the level of
the injury. In most cases both sides of
the body are affected equally.
Present when there is any distal
sparing of motor or sensory function
along with sparing of perirectal
sensation

 Diff dx of incomplete lesions

Central cord syndrome
Brown sequard syndrome
Anterior cord syndrome
Posterior cord syndrome
Isolated nerve root injury
Cauda equina syndrome (w/ or w/o root
escape)
Conus medullaris injury

Anterior Cord Syndrome

Damage is primarily in the

anterior 2/3 of cord and is
related to vascular
insuffiency
There is sparing the
posterior columns
Syndrome is manisfested
by complete motor
paralysis (corticospinal
func) and sensory
anesthesi (spinothalamic
func)
Patient demonstrates
greater motor loss in the
legs than arms

Prognosis
anterior cord syndrome has the worst
prognosis of all cord syndromes
prognosis is good if recovery is evident &
progressive during first 24 hours
after 24 hrs, if no signs of sacral sensibility
to pinprick or temp are present,
prognosis for further functional recovery
are poor; only 10 to 15% of patients
demonstrate functional recovery;

Central Cord Syndrome

most common incomplete cord lesion
frequently associated w/ extension injury
to osteoarthritic spine (cervical spondylosis
)in middle aged person who sustains
hyperextension injury
cord is injured in central gray matter, &
results in proportionally greater loss of
motor functionto upper extremities than
lower extremities w/ variable sensory
sparing;

Anatomy:
fibers responsible for lower extremity
motor and sensory functions are
located in the most peripheral part of
the cord
whereas fibers controlling the upper
extremity and voluntary bowel and
bladder function are more centrally
located
sacral tracts are positioned on the
periphery of the cord & are usually

Mechanism of Injury:
hyperextension injury
central cord injury and hemorrhage
occur with compression of adjacent
white-matter tracts
more peripheral positioning of lower
extremity axons within the spinal
cord tracts accounts for the injury
pattern

 damage tocentral portion of

corticospinal and spinothalamic long
tracts in white matter produces
upper motor neuron spastic paralysis
of trunk and lower extremity

Examination
central cord syndrome is remarkable for
more cord involvement in the upper
extremities than in the lower extremities
manifests w/ loss of distal upper extremity
pain & temperature sensation and
strength, w/ relative preservation of lower
extremity strength & sensation

upper extremities:
mixed upper and lower-motor-neuron lesion,
w/ partial
flaccid paralysis of upper
extremities (indicativeof involvement of
lower motor neurons)
prognosis is variable w/ poor hand function
lower extremities:
spastic paralysis of lower extremities
(indicative of involvement of upper motor
neurons)
bladder and bowel function may also be

Brown Sequard Syndrome

type of incomplete cord syndrome
injury to either side of spinal cord
produces ipsilateral muscle paralysis
(fromcorticospinal tract injury) and
contralateral hypersthesia to pain
and temperature (from spinothalamic
injury)

 syndrome results from

hemitransection of spinal cord w/
unilateral damage to the
spinothalamic & corticospinal tracts
and resultant loss of ipsilateral motor
& dorsal column function & of
contralateral pain and temperature
sensation
often due to penetrating trauma or
unilateral facet fracture or dislocation

Prognosis:
this syndrome has a good prognosis
for recovery
more than 90% of pts regain bladder
& bowel control & ability to walk
most patients will regain some
strength in lower extremities and
most will regain functional walking
ability;;

Cauda Equina Syndrome

urinary retention is the most consistent
finding
in spinal cord injuries, the caudal equina
may sustain considerable initial trauma
in any potential cauda equina syndrome
it is important to examine for saddle
anesthesia, rectal tone, bulbocaverosus
reflex, and sacral sparing;

Significance
Unstable if middle column + either Anterior or
Posterior column is damaged
Rupture of interspinous ligament is :
- associated with avulsion of spinous process
- Unstable spine
- Further flexion increases neurological injury

Level of Spinal injury

Neurological level is at the most lowest segment with
normal motor & sensory function
Difficult to determine :
- as most muscle efferents receive fibres from more
than one level
- Closed cord lesions may extend over several cms.
- Dermatomes have imprecise boundaries.

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