TRAUMA OF SPINE

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TRAUMA OF SPINE SPINAL CORD

• Dr K. Bougoulias
• Orthopaedic Trauma surgeon
• MSc Sports Exercise Medicine
• Diploma Orth and Trauma

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Objectives

• Incidence
• Anatomy
• Pathophysiology
• Classification
• Accident scene management
• Resuscitation
• Assessment
• Intervention

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Incidence

• 4.0 to 5.3 per 100.000 population 12000 new
  spinal cord inj per year
• ( Thurman et al, paraplegia 1994)
• Neurological deficits 10 to 25 with 40 in
  cervical spine and 20 thoracolumbar spine

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Incidence

• Motor vehicle accidents 45
• Falls 20
• Sports 15
• Acts of violence 15
• Other 5

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Anatomy

• 33 vertebrae 7 cervical, 12 thoracic, 5 lumbar,
  5 sacral,4 coccygeal
• Ligaments
• Intervertebral disc-nerve roots
• Lordosis- cyphosis
• 50 flexion extension C1 occiput
• 50 rotation C1-C2

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Topographic Landmarks

• Mandible
• Hyoid cartilage
• Thyroid cartilage
• Cricoid cartilage
• Vertebra prominence
• Scapular spine
• Distal tip of scapula
• Iliac crest

• C2-3
• C3
• C4-5
• C6
• C7
• T3
• T7
• L4-5

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Spinal cord

• Extends from brain stem to inferior border L1-
  Conus Medullaris-Cauda Equina
• Dorsal columns deep touch, proprioception,
  vibration
• Lateral spinothalamic tract pain, temperature
• Lateral corticospinal tract voluntary
  contraction
• Anterior spinothalamic tract light touch
• Anterior corticospinal tract voluntary
  contraction.

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Pathophysiology

• Kinetic injury is transferred by one of two
  mechanisms
• Direct flexion , extension, rotation
• Indirect impaction of bone or disc fragments

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Pathophysiology

• Contusion and compression rather complete
  transection
• Cord injury leads to petechial haemorrhages,
  myelin sheath and axoplasm disruption, edema
  within 6 hours, tissue hypoxia, cystic
  degeneration
• (Ducker et al, J neurosurgery, 1971)

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Classification

• Definitions by ASIA
• Complete injury No motor and/or sensory function
  exists more than three segments below the level
  of injury
• Incomplete injury some neurological function
  exists
• Level of injury The most caudal segment that
  tests intact (motor and sensory)

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Simplicity(Waters et al, 1991, Paraplegia)

• Sacral nerve root sparing indicates at least
  partial structural continuity
• Sacral sparing is diagnosed by Periannal
  sensation, rectal tone function, great toe flexion

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Complete injury

• Spinal shock for 24 hours, if more ,no functional
  recovery in 99 of patients
• (Stauffer 1975, Clin Orthopaedics)
• Exception injury to conus medullaris

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Incomplete Spinal cord Injury Syndromes

• Central cord Syndrome most common, quadriplegic
  with periannal sensation, early return of bladder
  bowel function, 75 recovery
• Anterior Cord Syndrome Complete motor and
  sensory loss- retained trunk and lower extremity
  deep pressure and proprioception- worst prognosis
  ( 10)

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Incomplete Spinal cord injury syndromes

• Posterior cord syndrome Rare, loss of deep
  pressure, deep pain, proprioception normal cord
  function otherwise
• Brown- Sequard unilateral cord injury,
  ipsilateral motor deficit, contralateral pain and
  temperature hypesthesia best prognosis gt90

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Accident Scene Management

• ATLS
• ABCD (Airway- Breathing- Circulation, C
  spine- Disability, neurological status)
• High level of suspicion
• Trauma patient is considered that has spine
  injury until prove otherwise

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Basic rules

• C spine secured before move from accident scene
• Sandbags on either side of head which is taped to
  backboard
• Full length backboard
• Repeat ABCD
• Transport

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High level of suspicion

• Frequently poly-trauma patients
• Facial injury C spine ?
• Thoracic abdominal Thoracolumbar Spine

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Neurogenic shock

• Hypotension with bradycardia due to disruption of
  sympathetic outflow and unopposed vagal tone
• ( Grundy et al, 1986)
• Zipnic et al ( J. Trauma 1993) showed that
  penetrating trauma differs from blunt trauma
• Out of 75 patients only 7 developed neurogenic
  shock

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Resuscitation

• No matter cause of hypotension, support of blood
  loss needs aggressive treatment by blood volume
  replacement.
• Vasopressors if hypotension without tachycardia
  persists
• Leg elevation to counteract venous pooling in
  extremities
• Atropine? maintain heart rate
• ? Gentle sympathomimetic agent ( e.g phenylephrine

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Assesment

• Secondary survay
• ABCDE
• Xrays
• Intubation always with a jaw thrust manuever
• Responsive patient Past history, location pain,
  sensation (marked on skin), motor function,
  Reflexes

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Unconscious patient

• Observation of spontaneous extremity motion
• Spontaneous respiration indicate normal thoracic
  innervation
• Log roll ecchymosis, abrasions (location), step
  off, interspinus widening

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Reflexes

• Spinal shock absent reflexes for 24h replaced by
  hyper-reflexia, muscle spasticity, clonus
• Spinal injury- concomitant head injury
• Extremity reflexes without spontaneous motion
  cranial upper motor neuron lesion
• Absence of reflexes lower motor neuron lesion

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Reflexes

• Babinski sign Oppenheims sign upper motor
  neuron lesion
• Cremasteric reflex T12-L1
• Annal wink S2, S3, S4
• Bulbocavernosus reflex S3, S4

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INTERVANTION

• Pharmacological
• High doses of intravenous methylprednisolone?
• Bracken et al (1990, 1991), controlled,
  randomized study MPS within first 8 hours
  improved neurologic recovery at 1 year
• Naloxone no better than control
• MPS after 8h, patient less function than placebo

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Intervention

• 30mg/ Kg body weight bolus
• Continuous infusion 5,4 mg/Kg/hr for 23h
• The earlier the administration the better the
  outcome
• More literature Kwon BK et al, 2004
• Wellman et al, 2003
• Bledsoe BE et al, 2004

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Physical Intervention

• Immobilization
• Reduction
• Stabilization

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THANK YOU