Spinal Injuries

1
Spinal Injuries

• Dr. Roberts

2
Epidemiology

• 8,000 to 10,000 cases yearly
• Spinal trauma occurs in lt1 of all trauma
• Mean age 33yo
• Male to Female 4 to 1
• Mostly from blunt trauma

3
Anatomy

• 33 vertebrae 7 C, 12 Thoracic, 5 Lumbar, 5
  sacral, 4 coccygeal
• Denis three-column system for classification of
  thoracolumbar injuries
• Anterior ant vertebral body, ant. annulus
  fibrosus, ant long. Lig.
• Middle posterior wall of vert. body, post
  annulus fibrosus, post long. Lig
• Posterior post vertebral arch
• if greater than two columns injured unstable
• if greater than 50 compression unstable

4
Classification of spinal column injuries

• Classified by mechanism
• Flexion, flexion-rotation, extension,
• vertical compression
• Flexion Atlanto-occipital or atlantoaxial
• joint dislocation simple wedge fracture flexion
  
• teardrop fracture clay shovelers fracture
• bilateral facet dislocations

5

• Damage to the corticospinaltract neurons (upper
  motor neurons) in the spinal cord results in
  (contralateral / ipsilateral) clinical findings
  such as muscle weakness, spasticity, increased
  deep tendon reflexes, and a Babinski sign.

6

• When the _tract is damaged in the spinal cord,
  the patient experiences loss of pain and
  temperature sensation in the contralateral half
  of the body.
• The (pain and temperature) sensory loss begins
  one or two segments below the level of the lesion.

7

• The dorsal columns transmit_.

8

• Injury to one side of the dorsal
• columns will result in (contralateral/ipsilateral)
  loss of vibration and position sense.

9

• beginning with Tl, nerve roots exit (above/below)
  the vertebral body for which they are named.

10
Atlantoaxial Dislocation
11
Simple Wedge Fracture
12
Flexion Tear Drop Fracature
13
Clay Shovelers Fracture
14
Bilateral Facet Dislocation
15
Classification of spinal column injuries

• Shear odontoid fractures

16
Classification of spinal column injuries

• Rotation Rotary atlantoaxial dislocation
  Unilateral facet dislocations

17
Classification of spinal column injuries

• Extension Posterior neural arch fracture of C1
  hangmans fracture extension teardrop fracture

18
Classification of spinal column injuries

• Vertical Compression Compression fractures

19
Neurologic Evaluation

• MOTOR EXAMINATION
• C4 Spontaneous breathing
• C5 Shrugging
• C6 Elbow Flexion
• C7 Elbow Extension
• C8-T1 Flexion of fingers
• T1-T12 Intercostal Abdominal muscles
• L1-L2 Hip Flexion
• L3 Hip Adduction
• L4 Hip Abduction
• L5 Foot Dorsiflexion
• S1-S2 Foot Plantar flexion
• S2-S4 Rectal Sphincter Tone

20
Neurologic Evaluation

• Spinal Reflex Examination
• C6 Biceps
• C7 Triceps
• L4 Patellar
• S1 Achilles

21
Neurologic Evaluation

• Spinal Sensory Exam
• C2 Occiput L4 Knee
• C3 Thyroid Cartliage L5 Lateral Aspect of Calf
• C4 Suprasternal Notch S1 Lateral Aspect of Foot
• C5 Below Clavicle S2-4 Perianal Region
• C6 Thumb
• C7 Index Finger
• C8 Small Finger
• T4 Nipple Line
• T10 Umbilicus
• L1 Femoral Pulse
• L2-3 Medial Aspects of Thigh

22
Neurologic Evaluation

• Complete lesions total loss of motor
  sensation
• Spinal shock may mimic
• May last several days bulbocavernosus reflex
  marks end of shock
• Sacral sparing
• Perianal sensation, normal rectal sphincter tone,
  flexor toe movement

23
Neurologic Evaluation

• Incomplete Spinal Lesions
• 90 are of three syndromes
• Central Cord
• Brown-Sequard
• Anterior Cord

24
Neurologic Evaluation

• Other 10
• Posteroinferior cerebellar artery syndrome
  dysphageia, dysphonia, hiccups, vertigo,
  cerebellar ataxia
• Horners cervical sympathetic chain damage with
  ipsilateral ptosis, miosis, and anhidrosis
• Cauda equina perineal or bilateral leg pain,
  bowel/bladder dysfunction, perianal anesthesia,
  diminished rectal tone, lower extremity
  weakness
• SCIWORA

25
Radiography

• Nexus prospective study 34,069 patients _at_ 21
  EDs all but 8 of 818 patients with injuries and
  only one required surgical stabilization
• Criteria
• No midline cervical tenderness
• No focal neurologic deficit
• No intoxication
• Normal Alertness
• No painful distracting injury

26
Radiography

• Canadian Decision Rule 3 questions
• Are there any high-risk factors that mandate
  radiography?
• Are there any low-risk factors that allow safe
  assessment of range of motion?
• Is the patient able to actively rotate the neck
  45 degrees to the left right?
• High Risks age gt 65 years mechanism (fall gt 1
  m, an axial load, MVC gt 100km/hr, rollover,
  ejection, ATV or bicycle collision) paresthesias
• Low Risks rear-end crashes, ability to sit up
  in ED, ability to ambulate, delayed onset of neck
  pain, absence of midline neck tenderness

27
Radiography

• Cross-Table Lateral View
• Three anatomical lines may be traced
• Along the anterior vertebral body cortex
• Along the posterior vertebral body cortex
• Along the spinolaminar junction
• 25 children have pseudosubluxation
• C2/3 no more than 2 mm
• retropharangeal soft tissues
• C1-4 4-7mm
• C5-7 16-22mm

28
Radiography

• Trauma Series
• AP/Lateral/swimmers/oblique/odontoid

29
Radiography

• Flex/Ext Views
• Ant. Or Post. Subluxation gt 2mm on one view and
  not on the neutral view ligament injury
• Only done if normal mental status exam, but
  still pain
• Controversial with CT/MRI available

30
Radiography

• MRI superior for non-osseous eval.
• CT
• Indications inadequate visualization
  suspicious plain films fracture/displacement on
  standard films high clinical suspicion despite
  normal plain films
• 3d reconstruction for complicated fractures

31
Unstable Fractures

• Jefferson fracture
• Hangmans fracture
• Flexion teardrop fracture
• Extension teardrop fracture
• Bilateral locked facets

32
Management

• Assume injury
• Immobilize
• Watch out for spinal shock
• Steroids?
• Definitive Care