SPINAL CORD INJURIES

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SPINAL CORD INJURIES

• M.R.EHSAEI M.D
• ASSOCIATE PROFESSOR OF NEUROSURGERY

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Anatomy of spine

• Complete spine contains
• 7 cervical
• 12 thoracic
• 5 lumbar
• 5 sacral
• 4 coccygeal
• Spinal cord protection
• Ligaments

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Ligaments of spine
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Vertebra (29) 7 cervical, 12 thoracic, 5
lumbar, 5 sacral Conus medullaris at L1-2
vertebrae 31 spinal cord segments 8 cervical,
12 thoracic, 5 lumbar, 5 sacral, and 1
coccygeal C1 dorsal roots missing in some
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Cerebrospinal fluid Clear 50-200 mm H2O
pressure 0-10 WBC 0 RBC lt 45 mg/100
ml protein glucose 2/3 blood level
50-80 mg/100 ml
Spinal tap done at L3-L4
Dural sac ends at vert. S1-S2
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Cervical Spine

• C1 Atlas
• C2 Axis
• Vertebral canal space for spinal cord
• Intervertebral foramen nerves exit from canal

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Anatomy of spine

• Anterior column
• Half of Vertebral bodies and intervertebral disc
• Anterior longitudinal ligament
• Middle column
• Half of Vertebral bodies and intervertebral disc
• posterior longitudinal ligament
• Posterior column
• Pedicles, facet joints, lamina
• Supraspnious, interspinous, infraspinous ligaments

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SPINAL CORD INJURIES
Car Crashes 83 Motorcycle incidents
10 Bicycle accidents 3
Medical/Surgical Complications 38 Hit by
falling Object 30 Pedestrian 22
Gunshot 92 Personal Contact 6
Diving 55 Snow skiing 8 Surfing 6
Source National Spinal Cord Injury Statistical
Center
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Epidemiology

• Spinal injury
• Motor vehicle crashes 41
• Falling down 21
• Sporting activity8
• Human violence22
• Others8
• Average age 34yrs
• MF 41

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Epidemiology

• Approx. 100,000 new cases/year, 80 male. Age
  group most commonly injured 16-30 years (43)
  and 31-45 (28).
• Although Vehicle is the leading cause overall,
  Falls become the leading cause in people over 60
  years.

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Spinal Cord Injuries

• Traumatic injury of vertebral and neural tissues
  due to compressing, pulling or shearing forces
• Most common locations cervical (12), cervical
  (4-7), and 12th thoracic 2nd lumbar vertebrae
• Locations reflect most mobile portions of
  vertebral column and the locations where the
  spinal cord occupies most the the vertebral canal

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Spinal Cord Injuries

• Vertebral injury can occur due to fracture,
  dislocation, or both.
• Within minutes after injury, hemorrhages appear
  in the central gray matter, pia, and arachnoid.
• Local hemorrhages reduce vascular perfusion

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Cervical spine
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Spinal Cord Injuries
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General Symptoms Signs

• Pain Tenderness
• Skin abrasions or contusions
• Subcutaneous Hematoma
• Muscle Spasm
• Cripitation in Touch
• Spinal Deformity

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Neurological Exam

• Detection Documentation
• Sensory Level
• Posterior Column function
• Sacral Sensory Sparing
• Muscle Weakness (0 - 5 )
• Pathological Reflex (BCR Babinski)
• Rectal Exam for Tone cotracture

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Neurological evaluation

• Complete inj.no motor or sensory function below
  the zone of inj.
• Incomplete inj.partial preservation of motor or
  sensory function below the zone of inj.

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Neurological evaluationcervical inj.

• Incomplete inj.
• Ant cord syn.
• Central cord syn.
• Brown-sequard syn.
• Post.cord syn.
• Spinal shock
• hypotension without tachycardia
  (motor,sensory,and reflexes are absent but cannot
  determine complete inj.until bulbocavernosus or
  other reflexes return within 24 houres.)

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Incomplete Spinal Cord Lesions

• The anterior cord syndrome
• cervical flexion injuries causing cord contusion
• protrusion of a bony fragment or herniated
  intervertebral disk into the spinal canal
• laceration or thrombosis of the anterior spinal
  artery
• rarely, systemic embolization or prolonged
  cross-clamping of the aorta during resuscitation
  or surgery

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Incomplete Spinal Cord Lesions

• central cord syndrome (m/c)
• affects the central gray matter and the most
  central portions of the pyramidal and
  spinothalamic tracts
• a greater neurologic deficit in the upper
  extremities than in the lower extremities

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Incomplete Spinal Cord Lesions

• The Brown-Séquard syndrome, or hemisection of the
  spinal cord
• a penetrating lesion such as a gunshot or knife
  wound
• ipsilateral motor paralysis and contralateral
  sensory hypesthesia distal to the level of injury
  

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Neurologic status frankel scale

• a) no motor or sensory function
• b) sensation but no motor function
• c) motor function present but useless
• d) motor function present but useful
• e) normal motor and sensory

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Neurologic exam cervical inj.

• C4(spont.breathing),C5(deltoids and biceps)
  C6(wrist ext.),C7(triceps and wrist ext.),C8
  (finger flex.),T1(intrinsics).
• SensoryC5(upper outer arm),C6(thumb),C7 (long
  finger),C8(little finger),T1(medial forearm).

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Prognosis of spinal cord inj.

• Complete inj usually remains complete,but one or
  two level recovery is expected.
• Incomplete inj.have potential for significan t
  recovery, particlarly in bronwn-sequard and
  central cord syn.

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Prognosis of spinal cord inj.

• Gunshot wound to the spine with spinal cord
  inj.carry a poor prognosis for recovery.
• Spinal cord recovery is better if bony impingment
  is removed for incomplete type.
• Patients with congenital C1-C2 instability and
  congenital stenosis have higher incidence of
  spinal cord inj.

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Prognosis of spinal cord inj.

• Patient with ankylosing spondylitis often sustain
  unstable three-column inj.,even with minor
  trauma.
• High dose corticosteroid is administrated early
  to patient within 8 hours of inj. to improve the
  prognosis.

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RADIOLOGICAL studies

• Plain x-ray
• Ap--LAT--Open mouthOblique- Pillar
  view--Stretch test--Flexion/Extension view
• Tomography
• C.T scan best modality for bony lesion.
• Myelography
• C.T myelography
• M.R.I best for soft tissue and give prognosis
  after inj.

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RADIOLOGICAL studies cervical inj.Plain X-Ray
LATERAL

• must see C7-T1(obtain swimmers view if
  necessary)
• soft tissue ant. to the cervical spine 10mm at
  C1,4-5mm at C2-C4, up to 15mm at C4-C7.
• Loss of lordosis may be an important sign.
• Vertebral alignment more than 3.5mm
  displacement, and 11degree angulation are
  significant for instability.
• spinal canal diameter17mm (N),less than
  14mm(Abnor).

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RADIOLOGICAL studies cervical inj.Plain X-Ray

• Obliques intervertebral and pedicles.
• Pillar view(hyperextention and 35 rotation)
  lateral masses between facets.
• Stretch testgt1.7mm and 7.5angulation on
  rotation signifies post. instability.
• Flexion/Extension viewLig.inj.(usually preformed
  3 weeks later.

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Upper cervical inj.

• occipital condylar fx.
• occiput-c1 dislocation.
• C1-C2 subluxation.
• fracture of C1.
• frature of odontoid.
• fracture through the pedicle of C2.

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Occipital condylar fx.

• diagnosis with tomogram or C.T scan.
• lig.inj, I.c.hematoma,and neurological deficit
  may accompany this inj.
• treatment
• usually rigid orthosis or halo vest for 3 m.
• flex/ext film is obtained at 3 m.
• occiput to c2 fusion if resultant instability.

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occiput-c1 dislocation
flex/ext force on the head. disruption of all
lig. unstable and always fatal. treatmentoccipu
t-c1 fusion.
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C1-C2 subluxation

• Rupture of transverse lig.
• Atlantodens interval
• 3-5mm indicate rupture of transverse lig.
• gt7-8mm indicate all lig.disruption.
• gt10mm causes spinal cord compression.
• Treatment
• if instability 3-5mmgthalo for 2-3 m then
  dynamic study repeated.if instability gt4mm then
  needs fusion c1-c2.
• if instability gt5mm then early fusion c1-c2.

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C1-C2 subluxation

• Atlantoaxial rotatory fixation the head is
  tilted toward the side of fixation and the chin
  and c2 spinous process is pointed toward the
  opposite direction.
• Type 1 rotatory fixation with no ant.
  displacement.
• Type 2 rotatory fixation with 3-5mmant.displacem.
  
• type3 rotatory fixation withgt5mm ant
  displacement
• Type4rotatory fixation with post.displacement.
• tratment reductionc1-c2 fusion if unstable.

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Stable Upper cervical Injuries

• Atlas fractures
• ant. arch fx.
• post. arch fx.
• lat. mass fx.with less displacement.
• Axis fractures
• type 1 odontoid fx.
• hangman fx.without angulation.

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Fracture of C1

• Axial loading usually with breaks at two sites.
• gt7mm widening of lat.massgttrnsverse lig.rupture
  .gtfirst immobilization with hallo for 2-3m and
  C1-C2 fusion may be performed if instability is
  greater than 5mm.

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Fracture of C1

• TREATMENT
• Cervical orthosis for 3 m if nondisplaced.
• Halo vest for 3m if displaced or delayed union.
• Posterior C1-C2 fusion if nonunion.
• If C1-C2 instability with gt7mm lat.mass displa.
  halo traction for 4-6w and halo vest for 6w. if
  unable to tolerate prolonged trction,early C1-C2
  fusion is recommended.

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Fractures of odontoid

• Type 1rare,avulsion fracture of the tip. stable
  and treatment is cervical collar.
• type 2 fracture at the base of the odontoid.
• ant .displ.(flex.inj.) is more common than post
  displ.(ext.inj.).
• nonunion rate is 20-80 especially age gt50 y.
• Type 3fracture through the body.
• nondisplaced cervical orthosis or halo.
• displaced halo jacked for 3m.

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ODONTOID FX

• FIXATION OF ODONTOID

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Fractures through pedicle of C2

• Mechanism of Hangman fracture ext.inj.
• Types
• type 1 minimal displacement(less than 3mm)
• type 2 significant displacement (gt3mm) and
  angulation(gt11 deg.)
• type 2A minimal displacement(lt3mm) and
  angulation(gt11 deg.)
• type 3 associated facet dislocation.

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Fractures through pedicle of C2

• Treatment
• type 1 halo jacket for 12 w.
• type 2traction for 2-3w for reduction halo for
  10-12w.
• type 2A no traction,extention,and
  compression,halo for 3m.
• type 3 or late instability or nonunion ant.C2-C3
  fusion or post pedicular screw fixation(C2-C3
  plating.

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FRACTURE AND DISLOCATIONS OF LOWER CERVICAL SPINE

• CLASSIFICATION

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CLASSIFICATION(ALLEN)

• Distructive flexionperched facet,unilateral or
  bilateral facet dislocation.
• Vertical compressionburst fx.
• Compressive flex. comp.fx.tear drop fx.
• Compressive ext.fx of post element body
• Lat.flexion uncommon.
• Distractive ext.widening of disc or
  retrolisthesis.

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M.R.I of cervical

• At C4-C5 , Disruption and Widening of the
  intervertebral Disc, compression fracture of C5,
  anterolisthesis of C4-C5

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Facet fracture/dislocation

• UNILATERAL OR BILATERAL.
• MAY BE WITH DISC HER. CORD COMP.
• IN UNILATERAL DISPLACEMENT IS ABOUT 25
• IN BILATERAL DISPLACEMENT IS ABOUT 50 .

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Stable Lower Cervical Injuries

• unilateral facet dislocation
• compression fx.
• hyperextension injuries
• clay shoveler,s fx. (fx of s.p)
• SCIWORA

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Instability defined by

• X -rays
• plain ,C.T.S , M.R.I
• Clinical
• neurologic deficits
• persistant pain

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White diagnostic checklistgt5 is unstable

• ant element2
• post element2
• sagital translationgt3.5 mm or20 vertebra2
• sagital plan rotation gt 11deg.2
• poitive stretch test2

• cord damage2
• root damage1
• abnormal disc narrowing 1
• dangerous loading anticipated 1

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• Myelogram

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• C.T SCAN

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• C.T Myelogram

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Medical anagement
c.s.inj.

• Acute care
• prehospital management
• emergency room manangement
• Spinal orthoses

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prehospital Management
c.s.inj

• 1

All accident victims of any sort must be assumed
to have an unstable spine until prove otherwise.
immidiate immobilization of head and neck is
important
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prehospital Management
c.s.inj

• Check airway
• Mouth check for debrids and cleared.
• Oropharyngeal or nasopharygeal airway.
• Gentle intubation if indicated.
• Indication of intubation
• hypoventilation due to paralysis of the
  intercostal muscles.
• loss of conscious level with spinal injury.

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prehospital Management
c.s.inj

• Respiratory and circulatory manageme- nt at the
  scene of accident is critical.
• Because aspiration and shock are the primary
  cause of death in spinal cord injury victims.
• Supplemental oxygentherapy.
• Maintenace of B.P within normal limits.
• Foly catheter for output monitor.

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prehospital Management
c.s.inj

• Method of intubation
• Gentle manual traction
• Blind nasal intubation advocated
• In the presence of basilar skull fracture nasal
  intubation is contra -indicated.

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prehospital Management
c.s.inj

• assessment of circulation
• hypotension in a spinal cord injured patient may
  be result of loss of sympathetic tone with
  decreased periphera vascular resista- nce
  secondary to the neurological injury.
• this results in venous pooling and decrea -sed
  cardiac preload,which is exacerbated by lack of a
  reflex, sympathetically mediat -ed tachycardia.

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Transport of patient
c.s.inj

• patient should be placed in a supine position on
  a long backboard as soon as possible.
• immobilization of neck with sanbags.
• fixation of head with tape across the forehead.

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Acute evaluation and management in the

• Emergency room

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Emergency Room Manageent
_at_Respiratory function should be control
_at_
if the blood pressure remaine low despite
resu- scitation with intravenous fluids then a
pressor such as dopamine should be started and
titrat- rated to effect.
_at_Full skeletal x-ray chest-pelvis-spine in
patient with low GCS c.t scan should be
taked. 11 incidence of head and spine injury.
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Emergency Room Managememt
c.s.inj.

• Hypothermiadisruption of sympathetic nerve
  function at T8 or above that.
• If patient need life saving surgery ap and lat
  x-ray of cervical should be taked. if possible
  thoracolumbar area should also be imaged.

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Emergency Room Managememt
c.s.inj.

• Old method of treatment
• Hypothermia
• Hyperbaric oxygen
• Electomagnetic feilds
• DRUGS
• Steroids I.v (dexa-methylprednisolon)
• Lidocain I.v
• Opiate antagonist Naloxone

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Emergency Room Managememt
c.s.inj.

• High dose of methylprednisolon improve
  neurological outcome in spinal cord injury
  patients. (compared with placebo and naloxone)
• Adminestration dose within 4-8 h bolus
  dose 30 mg/kg/in 15min continue with 5.4 mg/h
  for next 23 h.

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Emergency Room Managememt
c.s.inj.

• other protecols
• calcium channel blockers----gt nimodipine
• medulators of exitotoxicity----gt
  phencyclidine ,dextrophan.
• blockers of lipid peroxidation and membrane
  destruction----gt 21-amino steroids and GN1
  gangliocyte.

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Emergency Room Managememt
c.s.inj.

• After diagnostic cervical spine films are
  obtained,unstable or displaced spinal column
  injuries should be initially treated wit cervical
  traction.
• Most common type of traction is Gardner- wells
  tongs.
• The amount of weight5 pound per vertebral level
  above the fx/dis.

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Emergency Room Managememt
c.s.inj.

• Complication of traction
• overdistraction
• tong dislocation
• pin site infection
• skull penetration

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Management with spinal orthses

• GOALS of immobilization by s.ort
• reduce motin in unstable segment.
• reduce pain .
• correct deformity.
• protect the spinal cord.

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Who is the best orthoses for?

• _at_Less rigide orthoses
• _at_More rigide orthoses

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Four type of cervical orthoses

• Collars
• soft collar and philadelphia collar
• Poster-type orthoses
• gliford and somi
• Cervicothoracic devices
• minerva body jaket
• Halo orthoses halo vest

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• Miami-Jackson collar
• For cervical stabilization

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• Guilford brace

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• Occipitoatlantoaxial fusion with the Luque
  rectangle

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• CERVICAL PLATE

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• Ant. Odontoid
• Scrow
• fixation

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Thoracic Thoracolumbar
Spine Fx.
Compression Fx. Burst Fx. Seat
belt Fx. Fx. dislocation
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Compression Burst Fx.
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FOUR SUBTYPE OF WEDGE COMPRESSION FX.
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Burst fractures
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seat belt-type injuries
One level

• Chance fx.
• Through the bone

Two level
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Decreasing of body height (D E / D ) .
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Shearing Fracture
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Burst Fx. With Rotation
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Flexion-rotation type inj.

• Through the bone (slice fx.)
• Through the disc

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LISTHESIS
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Sacrum Fx.
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• Tkank you

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Clinical Paraclinical Presentation in
Thoracolumbar Injury
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General Symptoms Signs

• Pain Tenderness
• Skin abrasions or contusions
• Subcutaneous Hematoma
• Muscle Spasm
• Cripitation in Touch
• Spinal Deformity

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Neurologic Injury

• 10 - 38 all TL Injuries
• 50 Fracture-Dislocations
• Trauma between T5 - T9 has more chance for N.D.

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Neurological Exam

• Complete or Incomplete
• Frankel Classification
• ASIA Motor index Score
• Repeated Examination

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Frankel Classification

• A Complete loss(motor sensory)
• B ,, motor loss,some sensory
• C Motor useless, Sensory good
• D Motor useful , but weak
• E Neurologically Intact

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ASIA motor index score
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ASIA motor index score
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Neurological Exam

• Dtection Documentation
• Sensory Level
• Posterior Column function
• Sacral Sensory Sparing
• Muscle Weakness (0 - 5 )
• Pathological Reflex (BCR Babinski)
• Rectal Exam for Tone cotracture

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Prognostic Signs

• Spinal shock
• Bulbocavernosus Anal Reflexes
• Some return of Motor or Sensory function

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Clinical Syndromes

• mixture of Cord Root Syndromes. (T11 - L2
  ) complete sacral cord Damage variable
  sparing of the lumbar roots.
• (the most common syndrome) incomplete sacral
  cord lesions (less common)

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Clinical Syndromes

• solitary or multiple Radiculopathies
• Cauda equina syndrome

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Imaging

• X- Ray
• 5-20 F are multiple
• 5 at noncontaguious level
• Lateral View
• Oblique Views
• A-P View
• Flexion Extension Views (CI)
• A-P View of Pelvis

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Abnormalities in X-Ray

• Abnormalities of Alignment
• Kyphotic angulation
• loos of lumbar lordosis
• Vertebral disruption

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Abnormalities in X-Ray

• Disc space Narrowing
• Naked Facets
• interspinous distance Widening
• Paraspinal soft tissue mass
• Loss of the psoas stripe

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Imaging

• CTScan
• on areas suspected
• bone soft tissue windows
• 4 - 5- mm -thick
• Sagital re-formation

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Imaging

• MRI
• Adventages
• better visualization of the cord Ligaments
• Multiple plan of images
• Disadventages
• restriction for life support Equipments
• motion artifact
• marginal bony detail

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Complications of Spinal Cord Injury
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All Organs will be involved

• 2 Main cause1 - Immobility2- loss of central
  control ( paralysis )

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Skin

• Decubitus Ulcer
• Sacrum
• Occiput
• Heel
• Shoulder
• Trochanter

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Skin Ulcers

• Prevetion
• Roto-Rest table
• Skin Hygiene

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Skin Ulcers

• Treatment
• Cost 75000

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Respiratory

• Most common complications in quadriplegic
  Patients in ICU

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Respiratory

• Cause of Complications
• Paralysis of Muscle
• Secretions Stasis
• Atelectasis
• Direct trauma to lung

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Respiratory Complications

• Pneumonia
• Pneumothorax
• Plural efusion
• Lung abscess

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Respiratory Complications

• Treatment
• Profilactic Intubation
• nasotracheal Route
• above C4 Elective Tracheostomy
• Periodic monitoring Exam X-Ray Ultasound

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Cardiovascular

• Arrhythmias
• Phlebitis
• Deep vein thrombous
• Pulmonary emboli
• Fatal Type 3 - 13

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Cardiovascular

• Prevention
• Constant EKG monitoring
• CVP Swan-Ganz catheter
• prophilactic Heparin
• Compression leg devices
• Kinetic therapy

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Urinary System

• frequent Infectinos
• Calculus Formation
• Incotinance
• Retention

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Urinary Complications

• Prevention
• maintain good urinary output 400 ml/4h
• Culture from Foley/ per 4 days
• Intermittent Catheterization /per 4 h

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Gastrointestinal

• Ileus
• Acid hypersecretion
• GI Ulcerations
• GI Hemorrhage
• chronic Constipation
• Pancreatitis

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GastrointestinalComplications

• Prevention
• H2 blocker or similar drugs
• Gastric secretion drainage
• central Hyperalimentation
• start feeding after good bowel sound

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Skeletal System

• Massive Ca moblization
• urinary stones
• heterotopic Bone
• osteoporosis
• high risk of Pathological fr

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Psycological complications

• Denial Phase
• Anger phase
• Depression phase
• Coping Phase

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Miscellaneous complications

• Sepsis
• Most common cause of Morbidity in Spinal injury
• urinary or bed sore
• Catabolic state
• Neurogenic Hypotension

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• Burst Fx L1

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• Burst Fx

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