Spinal Traumas
Fisseha G (MD)
Contents
• Basic neuroanatomy and physiology
• Mechanism & causes of spinal injury
• Types of spinal injury
• Approach to a patient with spinal injury
• Management of spinal injuries
Anatomy
• The spinal cord is roughly cylindrical in shape.
• The spinal cord
– begins superiorly at the foramen magnum in the
skull, where it is continuous with the medulla
oblongata of the brain.
– terminates inferiorly
• in the adult at the level of the lower border of the first
lumbar vertebra.
• In the young child, it is relatively longer and usually ends
at the upper border of the third lumbar vertebra.
Anatomy…
• It occupies the upper two-thirds of the
vertebral canal of the vertebral column and is
surrounded by the three meninges,
– the dura mater, the arachnoid mater, and the pia
mater.
• In general spinal cord is protected by:
– Vertebral bones and associated soft tissue
– CSF
– Meninges
Anatomy….
• Inferiorly,
– the spinal cord tapers off into the conus
medullaris,
– From the apex of conus medularis a prolongation
of the pia mater, the filum terminale, descends to
be attached to the posterior surface of the coccyx.
(1) Anterior longitudinal ligament;
(2) intervertebral disc and posterior longitudinal ligament;
(3) facet joint capsule;
(4) interspinous ligament;
(5) supraspinous ligament
The three-column concept of spinal stability
• The spinal column can be divided into three
columns:
- Anterior
- middle and
- posterior.
• When all three columns are injured the spine
is unstable
The three-column concept of spinal stability
Pathways
Spinal Cord Injuries
• The incidence of spinal cord injury ranges from 27
to 47 cases per million population per year.
• Road traffic accidents remain the leading cause of
spinal cord injuries worldwide.
• Causes in US include:
– Motor vehicle accidents: 47%
– Falls: 23%
– Violence (especially gunshot wounds): 14%
– Sports accidents: 9%
– Other: 7%
Spinal Cord Injuries
• There should be a high index of suspicion of
spinal cord injury if any of the following are
evident:
– neurological deficit;
– multiple injuries;
– head injury;
– facial injury;
– high-energy injury (e.g. fall from a height);
– abdominal bruising from a seatbelt, suggestive of a
possible lumbar spine injury.
Spinal Cord Injuries…
• Spinal injuries often result from high-velocity
trauma and associated injuries are common:
– spinal injury at another level: 10–15% of cases;
– head and facial injury: 26% of cases;
– major chest injury: 16% of cases;
– major abdominal injury: 10% of cases;
– long bone/pelvic fracture: 8% of cases.
Spinal Cord Injuries…
• Sites of spinal trauma:
– Cervical 40%
– Thoracic 10%
– Lumbar 38%
Spinal Cord Injuries
• Neurologic injury can be:
- Immediately (primary injury) or
- In delayed fashion (secondary injury)
• Immediate neurologic injury may be due to
direct damage to the spinal cord or nerve
roots from penetrating or blunt injuries,
especially from stab wounds or gunshots
Primary Injury
• occurs when the skeletal structures fail to
dissipate the energy of the primary mechanical
insult, resulting in direct energy transfer to
the neural elements.
• The injury may occur directly by
– flexion, extension,
– axial loading, rotation or traction, or
– compression of the cord by a fragment of bone
and/or disc material.
Secondary Injury
• Is caused by:
- Hemorrhage
- Ischemia
- Edema
- Recurrent injury during:
- transport,
- examination,
- improper mobilization
Mechanics of Spine Trauma
1. Flexion
– Bending the head and body forward into a fetal
position flexes the spine.
– Flexion loads the vertebral bodies anteriorly and
distracts the spine posteriorly (the spinous process
and interspinous ligaments).
2. Extension:
– Extension loads the spine posteriorly and distracts
the spine anteriorly
3. Compression/Distraction
• Force applied along the spinal axis (axial loading)
compresses the spine.
• Compression loads the spine anteriorly and
posteriorly.
• High compression forces occur when:
- falling object strikes the head or shoulders, or
- landing on the feet, buttocks, or head after a fall
from height.
4. Rotation
• Force applied tangential to the spinal axis
rotates the spine.
• Rotation depends on the range of motion of
intervertebral facet joints.
• High rotational forces occur during off-center
impacts to the body or head or during glancing
automobile accidents
Level of Spinal injury
• Neurological level is the lowest segment with
normal motor & sensory function
• Usually is determined by sensory examination
of the dematomes
• Neurological level could be used to assess the
site of spinal chord injury
Level of Spinal injury…
• Upper cervical – cord level is on the same
level of vertebrae
• Lower cervical and upper thoracic- subtract 1
form the level of vertebrae
• Middle thoracic – subtract 2
• Lower thoracic and Lumbar – subtract 3 or 4
levels
Terminologies
• Plegia = complete lesion
• Paresis = some muscle strength is preserved
• Tetraplegia (or quadriplegia)
– Injury of the cervical spinal cord
– Patient can not move all limbs
• Paraplegia
– Injury of the thoracic or lumbo-sacral cord, or cauda equina
• Hemiplegia
– Paralysis of one half of the body
– Usually in brain injuries, or brown sequard syndromes
• Monoplegia
Severity /degree of Cord injury
• Complete (spinal cord transsection)
– flaccid paralysis + total loss of sensory & motor functions below the
level of the injury.
• Incomplete –
– There are various degrees of motor function in muscles controlled
by levels of the spinal cord caudal to the injury.
– Sensation is also partially preserved in dermatomes below the area
of injury.
– This include:
• Anterior sc syndrome
• Posterior sc syndrome
• Central cord syndrome
• Brown sequard’s syndrome
• Cauda equina syndrome
1. Anterior spinal cord syndrome
• Caused by:
- Flexion and rotational force to spine
- Due to compression fracture of vertebral body or anterior
dislocation
- Anterior spinal artery compression
• Clinical features:
– Bilateral loss of power, reduced pain and temperature below
the lesion
– Urinary incontinence
– Tactile, position, and vibratory sensation are normal.
• Posterior column function is preserved but the
prognosis is poor
2. Posterior cord syndrome
• Caused by:
- Hyperextension injuries
- Posterior vertebral body fracture
• Clinical features:
- Loss of proprioception and vibration sense
- Severe ataxia
3. Central cord syndrome
• Results from injury to the central portions of
the spinal cord
• Causes
- Older age with cervical spondylosis
- Hyperextension with minor trauma
- Cord is compressed by osteophytes from vertebral
body against thick ligamentum flavum.
Central Cord Syndrome…
• Clinical features:
– Distal motor function in the legs is typically spared
– the upper limbs and hands may be profoundly
affected.
– a variable degree of sensory loss below the level
of injury
• Younger patients often recover substantially but may
be left with a permanent loss of fine motor function
of the hand
4. Brown Sequard syndrome
• Hemisection of the cord
• Involves the dorsal column, corticospinal tract,
and spinothalamic tract unilaterally
• Causes:
- Stab injury, bullet
- lateral mass
- fractures
Brown Sequard Syndrome..
• Clinical features:
– Ipsilateral
- Motor weakness
- Loss of proprioception
- Loss of two point discrimination
– Contra-lateral
- Loss of pain sensation
- Loss of temperature sensation
5. Cauda Equina Syndrome
• This is most frequently associated with large
central disc herniations at L4/5 and L5/S1.
• Patients typically describe numbness around the
perineum and down the inside of the thighs
(saddle paraesthesia)
• They may also be unable to pass urine and have
loss of anal tone.
• If possible, imaging and surgery should be
undertaken within hours of the onset of symptoms
as the prognosis deteriorates rapidly over time
Complications
• Thromboembolic events
– clinically significant DVT : 30%
– Fatal pulmonary embolus= 1–2%
– deaths within 3 mo of injury, highest risks in the first
3 weeks.
• Heterotopic ossification
• contractures and disuse atrophy
– avoided by physiotherapy, positioning and splinting.
– Surgical release
Complications..
• CVS
– Hypotension, bradycardia
– Autonomic dysreflexia: episodes of HTN with
headache, bradycardia, sweating
• RS
– Pneumonia
– Pulmonary embolism
– Pulmonary edema
Approach to the Pt
• Basic points
– Assume as every trauma patient has a spinal injury until
proven otherwise;
– All assessment, resuscitation and life-saving procedures
must be performed with full spinal immobilization
• History:
– Injury (type, mode, impact)
– Injury to other sites
– Neck or back pain
Approach to the Pt…
- Inability to use the extremities
- Fecal, Urinary incontinence or retention
- Symptoms of hypovolumia
- In a conscious patient spinal injury can be exclude
if:
- there is no pain;
- palpation of the spine is non-tender;
- neurological examination is normal;
- there is a pain-free range of movement;
- Comatos pt: consider until imaging usually CT
Approach to the Pt
• Physical examination
– Give focus to ABCDE
• Airway and C-spine protection
• Breathing (the pattern of breathing: apnea)
• Circulation:
- Hypo-volumic shock
- Neurogenic shock
• Disability
• Exposure
Approach to the Pt
• Spinal Examination
– Inspect
• Visible deformity
• Bleeding and swelling
• Laceration
– Palpate
• Tenderness
• Alignment of spines
• Logroll to move the pt
Neurologic examination
• Do complete examination
– Motor - Reflexes
– Sensory - CN
• On completion the following should be
known:
– the presence or absence of a neurological injury;
– the probable level of injury;
– whether the injury is complete or incomplete;
– the type of spinal cord injury;
Investigation
• Plain X-ray:
– shows 85% cervical fractures
• CT scanning
– remains the most sensitive imaging modality in spinal
trauma.
– Complex fracture patterns can be understood and an
accurate assessment of spinal canal compromise by
bony fragments can be made.
• MRI:
– best at visualizing the soft-tissue elements of the spine
Emergency management
• ABCDE –
– Put on intranasal oxygen
– IV fluid if BP<80mmHg & HR <50bpm
• Stabilize
– Logroll
– spinal board on transport
– Cervical collar
• Supportive care
– Catheterize
– Change position frequently
– Antipain
• H2 Antagonists & Heparin
Management
• Treatment complications
– CVS, RS and other complications
• Decompression and stabilization —
– There are currently no standards regarding the role,
timing, and method of vertebral decompression in
acute spinal cord injury .
– Options include
• closed reduction using traction and
• open surgical procedures.
– By Neurosurgeon or orthopedic spinal surgeon
Management …
Rehabilitation
• Psychological support
• Bowel and bladder care
• Physiotherapy
Prognosis
• Life expectancy following spinal cord injury
– Despite continuing improvements in survival life
expectancy remains reduced.
– For patients surviving at least one year after traumatic
SCI, life expectancy is approximately 90 percent of
normal.
• Most frequent causes of death include :
– Pneumonia,
– pulmonary emboli and
– septicaemia
Prognosis …
• Higher neurologic level and severity of injury
and older age at the time of SCI negatively
impact survival.
References
• Bailey & Love’s short Practice of Surgery 25th
edition
• Schwartz's 9th edition
• Upto date 21.6
Thank You
Case scenario
• Hx
– A 35-year-old man was galloping his horse when he
attempted to jump over a farm gate.
– The horse refused to jump, and he was thrown to the
ground.
– His head struck a log, and his head and neck were
excessively flexed.
• P. exam
– On initial evaluation in the ED after he had regained
consciousness, he was found to have signs and symptoms of
severe neurologic deficits in the upper and lower
extremities.
• Lateral neck X-ray:
– fragmentation of the body of the fourth cervical
vertebra with backward displacement of a large bony
fragment on the left side.
• P. Exam:
– After stabilization of the vertebral column by using
skeletal traction to prevent further neurologic damage,
a complete examination revealed that the patient had
• weakness of lt upper and lower limb,
• contralateral loss of pain and to sensation…
1. what additional finding do you expect?
2. What is the Dx of this pt?
