MANAGEMENT OF

SPINAL INJURY

LARONA HYDRAVIANTO
Department of Surgery
RSUD SIDOARJO

Introduction
SPINAL CORD
INJURY (SCI)

Global :
250.000
500.000
people
suffer
every
year

40- 80
cases
per
million
popula
tion

18 35
years
Male
:
femal
e=
4:1

Spinal Column Function

Anatomy
Vertebral
column
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 4 coccygeal

Spinal cord
31pairs of
spinal
nerves are
attached
to the
spinal cord
:
- 8 cervical
- 12
thoracic
- 5 lumbar
- 5 sacral
-1
coccygeal

 The dorsal roots of spinal nerves

contain afferent (or sensory) fibers
The ventral roots of spinal nerves
contain efferent (or motor) fibers

Goal of Spine Trauma

Care

Obtain healed & stable spine

Principles of Diagnosis
and Management

Spinal Immobilization

Spinal Immobilization

Spinal Immobilization

Contraindications to
neutral position

LESS MOVEMENT IS
BEST

Helmet Removal
Technique
2 Rescuers
Remove face mask and chin
strap
Immobilize head
Slide one hand under back of
neck and head
Other hand supports anterior
neck and jaw
Remove helmet
Gently rock head to clear
occiput
All actions should be slow and
deliberate

Diagnosis

Radiographic Imaging

NEXUS
NEXUS Criteria :
1. Absence of tenderness in the posterior
midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score =
15)
4. No evidence of intoxication (drugs or
alcohol)
5. No distracting injury/pain

fulfilled all 5 of
criteria low
risk for C-spine
injury No need
C-spine X-ray

any of the 5
criteria
radiographic
imaging was
indicated (AP,

Radiolographic
Evaluation
X-ray Guidelines (cervical)
AABBCDS

Adequacy, Alignment
Bone abnormality, Base of skull
Cartilage
Disc space
Soft tissue

Adequacy

Alignment

The anterior
vertebral line,
posterior
vertebral line,
and spinolaminar
line should have
a smooth curve
with no steps or
discontinuities
Malalignment
of the posterior
vertebral bodies
is more
significant than
that anteriorly,
which may be

Lateral Cervical Spine XRay

Anterior subluxation
of one vertebra on
another indicates
facet dislocation
< 50% of the width
of a vertebral body
unilateral facet
dislocation
> 50% bilateral
facet dislocation

Bones

Disc
Disc Spaces
Should be
uniform
Assess spaces
between the
spinous
processes

Soft tissue
Nasopharyngeal
space (C1)
10 mm (adult)
Retropharyngeal
space (C2-C4)
5-7 mm
Retrotracheal space
(C5-C7)
14 mm (children)
22 mm (adults)

AP C-spine Films
Spinous processes
should line up
Disc space should
be uniform
Vertebral body
height should be
uniform. Check
for oblique
fractures

Open mouth view

Adequacy: all of
the dens and
lateral borders of
C1 & C2
Alignment: lateral
masses of C1 and
C2
Bone : Inspect
dens for lucent
fracture lines

CT Scan

Thin cut CT scan should

be used to evaluate
abnormal, suspicious or
poorly visualized areas on
plain film
The combination of plain
film and directed CT scan
provides a false negative
rate of less than 0.1%
Unable to adequately
assess on plain films
Sagittal and/or coronal
reconstructions can be
helpful (particularly at
Occipitocervical and C-T
junction.)

MRI

Principle of treatment
Spinal column alignment
deformity/subluxation/dislocati
on reduction
Spinal column stability
unstable stabilization
Neurological status
neurological deficit
decompression

Spinal shock
Temporary loss of all or most
spinal reflex activity below
level of injury
Lasts around 24 hours (max 48
hrs)
Ends when bulbocavernosus
reflex and/or anal wink returns
An injury cannot be considered
Autonomic function/ loss of
complete until resolution of
sympathetic
spinal shock ( hypotension,
bradycardia) neurogenic shock

Pharmacologic Treatment
of Spinal Cord Injury
National Acute Spinal Cord injury
Study (NASCIS) II :
methylprednisolone
hours): significantly
neurologic recovery
after 8 hours: worst
(relatively high rate
complications)

(within 8
better
outcome
of

NASCIS III :
improved recovery when tx extended
to 48 hours (if drug therapy was
started within 3 to 8 hours)

Pharmacologic
Treatment
Dosage
:
of Spinal
Cord Injury

30
mg/kg
of
IV
methylprednisolone (for 1 hour)
followed
by
5.4
mg/kg
(administered over the next 23
hours)
if administered within 3 hours of
injury
when is initiated 3 to 8 hours
after injury : maintained for 48
hours

Jefferson Fracture
Burst fracture of C1
ring
Unstable fracture
Increased lateral
ADI on lateral film if
ruptured transverse
ligament and
displacement of C1
lateral masses on
open mouth view
Need CT scan

Burst Fracture
Fracture of C3C7 from axial
loading
Spinal cord
injury is common
from posterior
displacement of
fragments into
the spinal canal
Unstable

Optimal
treatment of
cervical burst
fractures is
anterior
corpectomy,
decompression,
reconstruction,
and plating

Clay Shovelers
Fracture
Flexion fracture
of spinous
process
C7>C6>T1
Stable fracture

Flexion Teardrop
Fracture
Flexion injury
causing a fracture
of the anteroinferior
portion of the
vertebral body
Unstable because
usually associated
with posterior
ligamentous injury

- Surgical intervention is
almost always indicated
- Anterior neural
decompression in the form
of corpectomy, followed by
reconstruction with
strutgraft or cage as well
as static anterior cervical
plating and posterior-

Bilateral Facet
Dislocation
Flexion distraction
injury
High incidence of
spinal cord injury
Extremely unstable

Hangmans Fracture
Extension
injury
Bilateral
fractures of C2
pedicles
(white arrow)
Anterior
dislocation of
C2 vertebral
body (red
arrow)
Unstable

Odontoid Fractures
Generally unstable
Type 1 fracture through
the tip
Rare
Type 2 fracture through
the base
Most common
Type 3 fracture through
the base and body of
axis
Best prognosis

Thoracic and Lumbar

Fractures

Stability of The Spine

Instability may cause :

1. Mechanical problem
Compression fracture that lead
to kyphotic deformity.
2. Neurological disturbance
Extraction of the bone fragment
into spinal canal regression
of the neurological function.

Both can happen

together

Denis Three Column

Concept

Denis classification of
thoracolumbar
fractures

Surgical treatment is
indicated for :

Compression fracture
Result from an axial
loading force acting on
a flexed spine
Usually stable
Can be treated
nonsurgically
Bracing for 6 weeks
with subsequent
physical therapy led to
a better outcome than
casting for 6 12 weeks

Burst fracture
Burst fracture with more than
50% height loss, 30 of kyphosis,
or a neurologic deficit riginally
were identified as unstable and
requiring surgical treatment
PLC is important in determining
the stability
The goal of treatment of is to
prevent the progression of
deformity and neurologic injury

Burst fracture
Hyperextension cast or
thoracolumbosacral orthosis for
8 12 weeks
Surgical option :
- Posterior approach
- Anterior approah
- Combined anterior-posterior
approach

Stable Burst fracture

Unstable Burst fracture

Flexion distraction
(Chance fracture)

Translation-rotation
injuries
Highly unstable shear injury or
fracture-dislocation
Requiring surgical stabilization

Fracture-dislocation