Spinal Injuries

Dr ABDELMONIEM SAEED
Introduction
The incidence
40cases per million,
mean age of 40 years old
male-to-female predominance of 4 to 1.
Ocure more frequently on weekends and holidays

The etiology is estimated to be

 42% due to motor vehicle collisions,
 27% due to falls,
15% due to acts of violence (primarily gunshot wounds),
8% from sports, and 8% from other mechanisms

Injury can affects

the bony elements (vertebral fracture)
the neural elements (spinal cord and nerve root injury)
or both

Injuries result from one or a combination of mechanisms: flexion, extension,

compression (axial loading), distraction, rotation, and lateral bending.
Mechanism of Injury
Mechanism of Injury
Blunt Injury
 Motor Vehicle-Related Injuries
 Falls
 Sports Injuries

penetrating spinal cord

 gunshot wounds.
 The spinal cord may be injured by
o direct contact with the bullet, by
o bone fragments, or from concussive forces..

 Stabbing injuries
 aremuch less common, including knives, axes, ice picks, screwdrivers,
and glass fragments.
Anatomical consideration
Spinal Stability
Spinal Stability
Is the ability of the spine to limit displacement under physiologic
loads so as not to damage or irritate the spinal cord or nerve roots

any patient with neurologic deficits or radiographic evidence of

injury should be considered to have an unstable injury.

methods of assessment include

1. an injury with separation of adjacent vertebral bodies or arches
obviously has enough ligamentous disruption to be unstable.

2. use of radiography to associate injuries with the potential for

instability based on clinical experience.

3. use of the Denis three-column principle to classify injuries as

stable or not
Spinal Stability
Denis three columns system include
The anterior column
is formed by the anterior part of the vertebral body, the anterior annulus fibrosus, and
the anterior longitudinal ligament.
The middle column
is formed by the posterior wall of the vertebral body, the posterior annulus fibrosus, and
the posterior longitudinal ligament.
 The posterior column
includes the bony complex of the posterior vertebral arch and the posterior ligamentous
complex.

The Denis principle is that for an injury to be unstable there must be

disruption of at least two columns.

One important addition to the three-column principle is the degree of

vertebral body compression;
vertebral body compressions of >25% for the third to seventh cervical
vertebrae
or >50% in the thoracic or lumbar vertebrae from an acute injury are
generally considered unstable.
Spinal Cord Lesions
Spinal Cord Lesions
complete neurologic lesion
Is the absence of sensory and motor function below the level of injury.
This includes loss of function to the level of the lowest sacral segment.

incomplete neurologic lesion

 if sensory, motor, or both functions are partially present below the
neurologic level of injury.

The differentiation between complete and incomplete spinal cord

damage may be complicated by the presence of spinal shock.

Patients in spinal shock lose all reflex activities below the area of
injury, and lesions cannot be deemed complete until spinal shock has
resolved
Anterior Cord Syndrome
results
 from damage to the corticospinal and spinothalamic pathways with
preservation of posterior column function.

This
 is manifested by loss of motor function and pain and temperature
sensation distal to the lesion. Only vibration, position, and crude touch
are preserved.
causes include
direct injury to the anterior spinal cord.
Flexion of the cervical spine may result in cord contusion or bone injury
with secondary cord injury.
thrombosis of the anterior spinal artery can cause ischemic injury to the
anterior cord.

overall
 prognosis for recovery of function historically has been poor and
remains so today.6
.
.
Central Cord Syndrome
seen in older patients with preexisting cervical spondylosis who
sustain a hyperextension injury.

Clinically, patients present with

decreased strength
decreased pain and temperature sensation
Spastic paraparesis or spastic quadriparesis can also be seen
more in the upper than the lower extremities.

The majority will have bowel and bladder control, although this may
be impaired in the more severe cases.

Prognosis for recovery of function is good; however, most patients

do not regain fine motor use of their upper extremities.
Brown-SéQuard Syndrome
results from hemisection of the cord.

 It is manifested by
ipsilateral loss of motor function, proprioception, and vibratory sensation,
 contralateral loss of pain and temperature sensation.

Causes include
penetrating injury the most common.

It can also be caused by lateral cord compression secondary to disk

protrusion, hematomas, bone injury, or tumors. Of all of the
incomplete cord lesions, Brown-Séquard syndrome has the best
prognosis for recovery
Cauda Equina Syndrome
composed entirely of lumbar, sacral, and coccygeal nerve roots.

An injury in this region produces a peripheral nerve injury rather than
a direct injury to the spinal cord.

 Symptoms may include

variable motor and sensory loss in the lower extremities,
sciatica,
 bowel and bladder dysfunction, and
saddle anesthesia
 loss of pain sensation over the perineum.

Because peripheral nerves possess the ability to regenerate, the

prognosis for recovery is better than that for spinal cord lesions
Clinical presentation
History

Examination

Investigation
Patients at High Risk for Cervical Spine Injury
Injury mechanism High speed (>35 mph or 56 kph combined impact) motor vehicle
crash

Motor vehicle crash with death of an occupant

Pedestrian stuck by moving vehicle

Fall from height >10 ft or 3 m

Primary clinical Significant or serious closed head injury*

assessment
Neurologic symptoms or signs referable to the cervical spine

Pelvic or multiple extremity injuries

Additional information Intracranial hemorrhage seen on CT

 Canadian Cervical Spine Rule for Radiography:
Question or Assessment Definitions
There are no high-risk High-risk factors include:
factors that mandate   Age 65 years or older
radiography.   A dangerous mechanism of injury (fall from a height of >3 ft; an
axial loading injury; high-speed motor vehicle crash, rollover, or
ejection; motorized recreational vehicle or bicycle collision)
  The presence of paresthesias in the extremities
There are low-risk factors Low-risk factors include:
that allow a safe   Simple rear-end motor vehicle crashes
assessment of range of
  Patient able to sit up in the ED
motion.
  Patient ambulatory at any time
  Delayed onset of neck pain
  Absence of midline cervical tenderness
The patient is able to Can rotate 45 degrees to the left and to the right
actively rotate his/her
neck.
Cervical Spine Imaging Unnecessary in Patients Meeting These Three Criteria
Jefferson Fracture
Is C1 (Atlas) fractures produced by axial load on
cervical as from a direct blow to the top of the head

Is burst fracture driving the lateral masses of C1 apart

producing outward displacement of the lateral masses on
the open-mouth odontoid radiograph

Instability results from disruption of the transverse

ligament

If displacement of both lateral masses (measured as

offset from the superior corner of the C2 body on each
side) is >7 mm when added together, rupture of the
transverse ligament is likely, and the spine is unstable
Transverse Ligament Disruption
located anteriorly on the inside of the ring of C1 and runs along the
posterior surface of the dens.

crucial in maintaining the stability of C1& C2

rupture without fracture can occur in older patients from a direct blow to
the occiput, as in a fall.

Without a fracture present, radiographic diagnosis relies on identifying the

atlantodens interval, also known as the

predental space,
is the space between the posterior aspect of the anterior arch of C1 and the
anterior border of the odontoid.
Normally should be 3 mm or less in adults when measured on a lateral
radiograph or 2 mm or less on CT images.

Diagnoses
Damage if space of >3 mm on a lateral radiograph (2 mm for CT images)
Rupture if space of >5 mm
Ct scan of 34-year-old woman involved in a
motor vehicle crash
Odontoid Fractures
Presented in conscious patients with
Immediate, severe high cervical pain with which may radiate to the occiput

Neurologic injury is present in 18% to 25% of cases ranging from minimal

sensory or motor loss to quadriplegia.

Classified according to the level of injury into

Type I fractures are avulsions of the tip. The transverse ligament remains
attached to the dens, the fracture is stable, and the injury carries a good
prognosis.

Type II fractures occur at the junction of the odontoid with the body of C2 and
are the most common type of odontoid fracture.

Type III odontoid fractures occur through the superior portion of C2 at the base
of the dens. Both type II and III odontoid fractures are considered unstable
Types of odontoidal Fractures
C-spine X-ray of 40year man involved in RTA
Hangman's Fracture
Is the fracture of both pedicles of C2 resulting in the displace of the body of
C2 to anteriorly on C3

It is caused by an extension mechanism and associated with judicial hangings.

Suicidal hangings do not usually cause associated with the hangman's fracture.

It occur in motor vehicle crashes and diving accidents, where sudden
hyperextension forces are applied in deceleration.

Owing to the large diameter of the spinal canal at the level of C2, even
displacement of C2 on C3 may not cause neurologic injury, and patients may
be neurologically intact
32-year-old man following a head-on collision while
playing football
CT and MRI 19-year-old man involved in a
motorcycle crash.
Burst Fracture
Result from direct axial load, with fragments displacing in all
directions

The spinal cord may be injured if a fragment enters the spinal canal.

The lateral radiograph may show fracture of the superior and

inferior end plates, and retropulsion of the posterior portion of the
vertebral body into the spinal canal.

The anterior radiographic view will show a vertical fracture through

the vertebral body and widening of the interpedicular distance. This
injury is unstable.
45yrs male fell from the third floor
wedge fracture
is caused by compression between two other vertebral
bodies.

Normally the superior end plate of the vertebral body

fractures while the inferior end plate remains intact.

The posterior ligaments may be disrupted and increase

the distance between the spinous processes.

wedge fracture is differentiated from a burst fracture by

the absence of a vertical fracture of the vertebral body.
Flexion-distraction injuries
 commonly seen following seat belt–type injuries,
particularly those in which lap belts alone are used

The seat belt serves as the axis of rotation during distraction,

and there is failure of both the posterior and middle
columns. The intact anterior column prevents subluxation.

Typical radiographic findings reveal increased height of the

posterior vertebral body, fracture of the posterior wall of the
vertebral body, and posterior opening of the disk space.
Flexion-distraction injuries are considered unstable.
Flexion-distraction fracture
52 yrs male involved in RTA
Chance fracture
Is a variant of flexion-distraction injuries

usually involves the interspinous ligament, ligamentum

flavum, facet capsule, posterior annulus, and thoracodorsal
fascia and it is unstable.

The presence of an anterior compression fracture in the

thoracolumbar transition zone (T11 to L2) in a restrained
young patient following a motor vehicle collision should
suggest the possibility of a Chance fracture

often misdiagnosed as an anterior compression fracture,

25yes male in RTA
Fracture-dislocations
are the most damaging of injuries

Compression, flexion, distraction, rotation, or shearing

forces lead to failure of all three columns.

The end result is subluxation or dislocation with a

grossly unstable spine
Teardrop Fracture
Results from Extreme flexion and more common in older patients with
osteoporosis.

The "teardrop
is the anteroinferior portion of the vertebral body that is separated and displaced from the
remaining portion of the vertebral body.
The height of the avulsed fragment usually exceeds its width

There is also complete disruption of the ligamentous structures at the level

of injury

is an unstable

Associated with the anterior spinal cord syndrome because of

impingement of the spinal cord on the fracture-induced hyperkyphosis.
Clay-Shoveler's Fracture
Result from avulsion of spinous process of one of the
lower cervical spinous processes, classically C7.

 This injury is caused by intense flexion against a

contracted posterior erector spinal muscle that
fractures the tip of the spinous process.

 An isolated spinous process avulsion fracture is

mechanically stable.
Treatment of Spinal Injuries
Prehospital Care

ED Stabilization

Neurologic Examination

Nonoperative Spinal Stabilization

Operative Management of Spine Injuries

Treatment of Spinal Injuries
Corticosteroids
High-dose methylprednisolone remains a controversial
treatment in acute blunt spinal cord injury
the National Acute Spinal Cord Injury Study (NASCIS)
 that methylprednisolone infusion resulted in improvement of both
motor and sensory function in patients with complete and
incomplete neurologic lesions.

This positive outcome was dependent upon dosage of

steroids and time of administration

Massive steroid therapy has not been found to be

effective in penetrating spinal cord injury
Algorithm for gunshot injury to spine
Operative Management of Spine Injuries
progressive neurologic deterioration is an indication
for urgent surgery
varies from institution to institution
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