SpinalTrauma

By: Abdullah Mohammad

Shifa College of Medicine
2014-001
  Traumatic Spinal Cord Injury accounts for 15,000 new cases each
year.
 Mortality/Morbidity
 94% of patients survive the initial hospitalization
 Life Expectancy is greatly reduced.
 Renal Failure was the leading cause of death in the past.
 Currently, Pneumonia, Pulmonary Emboli, and septicemia are the
major causes.

Introduction  Commonly men 16–30 years old (M:F Ratio 4:1)

 Mechanism of Injury
 Vehicle crashes: 48%
 Falls: 21%
 Penetrating trauma: 15%
 Sports injury: 14%
 25% of all spinal cord injuries occur from improper handling of the
spine and patient after injury.
Anatomy & Function
Spinal Cord Anatomy
anatomy
Cross-section
Fungsi Medulla Spinalis
• Pusat gerakan otot tubuh terbesar yaitu di kornu motorik atau kornu
ventralis.
• Mengurus kegiatan refleks spinalis dan refleks tungkai, Refleks merupakan
respon bawah sadar terhadap adanya suatu stimulus internal ataupun
eksternal untuk mempertahankan keadaan seimbang dari tubuh.
• Refleks yang melibatkan otot rangka disebut dengan refleks somatis dan
refleks yang melibatkan otot polos, otot jantung atau kelenjar disebut
refleks otonom atau visceral.
• Menghantarkan rangsangan koordinasi otot dan sendi menuju cerebellum.
• Mengadakan komunikasi antara otak dengan semua bagian tubuh.
Diagram Jalur Otonom
 Level Function
C1-C6 Neck flexors
C1-T1 Neck Extensors
Fungsi Motorik C3, C4, C5 Supply diaphragm (mostly C4)

C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally
rotates the arm (supinates)
C6, C7 Extends elbow and wrist ( triceps and wrist extensors);pronates wrist

C7, T1 Flexes wrist

Supply small muscles of the hand

T1 –T6 Intercostals and trunk above the waist
T7-L1 Abdominal muscles
L1, L2, L3, L4 Thigh flexion

L2, L3, L4 Thigh adduction

Extension of leg at the knee (quadriceps femoris)

L5, L5, S1 Thigh abduction

Dorsoflexion of foot (tibialis anterior)

Extension of toes
L5, S1, S2 Extension of leg at the hip (gluteus maximus)

Plantar flexion of foot

Flexion of toes
L5, L5, S1, S2 Flexion of leg at the knee (hamstrings)
DERMATOMES
  The spinal cord can be divided into three columns:
 Anterior, middle and posterior.
Denis: Three  Spinal stability is dependent on at least two intact
Column columns.
Concept of  When two of the three columns are disrupted, it will
allow abnormal segmental motion, i.e. instability.
spinal stability.
 Failure of two or more columns generally results in
instability.
Diagrammatic
representation
of the Three
Column
Concept of
spinal stability.
  Stable Injuries
 Vertebral components won’t be displaced by normal movement.
 An undamaged spinal cord is not in danger.
 There is no development of incapacitating deformity or pain.

Stable vs.  Unstable Injuries

Unstable  Further displacement of the injury may occur.
 Loss of 50% of vertebral height.
Injuries  Angulation of thoracolumbar junction of > 20 degrees.
 Failure of at least 2 of Denis’s 3 columns.
 Compression fracture of three sequential vertebrae can lead to post
traumatic kyphosis.
  The primary Injury
 When the skeletal structures fail to dissipate the energy of the
primary mechanical insult.
 Results in direct energy transfer to neuronal elements.
 Flexion
Types ofSpinal  Extension
 Axial Loading
Cord Injury  Rotation or traction
 Compression of the Cord

 Secondary Injury
 Hemorrhage, oedema, and Ischemia secondary to the insult.
 Therapeutic strategies are directed at reducing secondary injury.
  Extremes of Motion
Hyperextension:
 Common in the neck
 Anterior ligaments and disc may be damaged.
Hyperflexion:
 If posterior ligament is intact , wedging of vertebral body
Mechanisms of occurs.If torn , may cause subluxation.
Spinal Injury Axial compression:
 Causes burst fractures. Bony fragments may be pushed
into spinal canal.
Flexion with rotation:
 Causes dislocation with or without fracture.
Flexion with posterior distraction:
 May disrupt middle and posterior column
Shear
Spinal Cord
Injuries
  Neurologic function
 Above the injury: intact.

 Below the injury: absent or markedly diminished.

 Specific manifestations depend on the exact level and whether

cord injury is complete or incomplete.
Symptoms
and Signs  Vertebral injury typically is painful, but patients who are distracted
by other painful injuries (eg, long bone fractures) or whose level of
consciousness is altered by intoxicants or head injury may not
complain of pain.
Location of Injury Possible Effects

At or above C5 Respiratory paralysis and quadriplegia

Between C5&C6 Paralysis of legs, wrists, and hands; weakened shoulder

abduction and elbow flexion; loss of brachioradialis reflex
C6-C7 Paralysis of legs, wrists, and hands, but shoulder movement and
elbow flexion usually possible; loss of biceps jerk reflex
C7-C8 Paralysis of legs and hands

C8-T1 With transverse lesions, Horner's syndrom. e (ptosis, miotic

pupils, facial anhidrosis), paralysis of legs
T1-T12 Paralysis of leg muscles above and below the knee

At T12 to L1 Paralysis below the knee

Cauda equina Hyporeflexic or areflexic paresis of the lower extremities, usually

pain and hyperesthesia in the distribution of the nerve roots, and
usually loss of bowel and bladder control
At S3 to S5 or conus Complete loss of bowel and bladder control
medullaris at L1
  Approach every patient in the same manner using Advanced
Trauma Life Support Principles (ATLS).
 Assume every trauma patient has a spinal injury until proven
otherwise.
 All Assessment, Resuscitation and life saving procedures must be
performed with full spinal immobilization.
Basic Patient  Signs of spinal Injury:
Assessment  Polytrauma patient
 Neurological Deficit
 Multiple Injuries
 Head Injuries
 Facial Injury
 High energy Injury
 Abdominal Bruising from a seatbelt.
Spinal
Immobilization
  The Unconscious patient:
 Full Assessment of the spine is difficult.
 Definitive clearance of the spine many not be possible initially.
 Maintain Spinal Immobilization until MRI rules out injury.

Unconscious  The Pain-free patient:

and pain-free  There is no pain.
 Palpation of the spine is non-tender.
patient.  Neurological examination is normal.
 There is pain free range of movement.

 The mechanism and velocity of injury should be determined at an

early stage.
  InitialAssessment
 Be aware that spinal injury may mask signs of intra-abdominal
injury.

 Identification of Shock
 Three types of Shock may occur in spinal trauma:
Physical  Hypovolaemic Shock: Presents with hypotension, tachycardia, cold
Examination clammy peripheries. Caused by hemorrhage; treated with appropriate
fluid replacement.
 Neurogenic Shock: Hypotension w/ normal heart rate or bradycardia
and warm peripheries. Caused by unopposed vagal tone resulting from
cervical spinal cord injury above the level of the sympathetic outflow
(C7/T1).
 Spinal Shock: Characterized by paralysis, hypotonia, and areflexia.
Lasts for only 24 hours. Assess patient neurologically. When it starts to
resolve bulbocavernosus reflex returns.
Bulbocavernosus
reflex
The bulbocavernosus reflex (BCR)
or "Osinski reflex" is a polysynaptic
reflex that is useful in testing for
spinal shock and gaining
information about the state of
spinal cord injuries (SCI)
  Spinal Examination
 Spine Log Roll must be performed to achieve proper examination.
 Inspect and palpate entire spine.
 Swelling, tenderness, palpable steps or gaps suggest a spinal injury.
 Note the presence of any wounds that might suggest penetrating
trauma.

Spinal
Examination
  American Spinal Injury Association neurological evaluationsystem
is used.
 Motor Function assesses key muscle groups. Grade (0-5)
 Sensory Function assesses dermatomal map. (Pinprick and light
touch) Score: 0-2
 Rectal examination:
Neurological  Anal tone.
 Voluntary anal contraction.
Evaluation  Perianal sensation.

 What should be known after complete neurological examination?

 Presence or absence of neurological injury.
 Probable level of injury.
 Injury is complete or incomplete.
 Level of impairment.
 A Absent motor and sensory
function.
B Sensory function present, motor
function absent.

ASIA C Sensory function present, motor

neurological function present but not useful.
(MRC Grade<3/5)
impairment
scale
D Sensory function present, motor
function useful. (MRC Grade≥3/5)

E Normal Function.
  Transection leads to immediate, complete, flaccid paralysis (including
loss of anal sphincter tone), loss of all sensation and reflex activity,
and autonomic dysfunction below the level of the injury.

 High cervical injury (at or above C5) , causing

 Respiratory insufficiency especially in patients with injuries at or above
C3.

CompleteCord  Bradycardia and hypotension (neurogenic shock) .

 Arrhythmias and BP instability may develop.
Injury
 Flaccid paralysis gradually changes over hours or days to spastic
paralysis with increased deep tendon reflexes due to loss of
descending inhibition.

 Later, if the lumbosacral cord is intact, flexor muscle spasms appear

and autonomic reflexes return.
 Partial motor and sensory loss occurs, and deep tendon reflexes
may be exuberant. Rapid swelling of the cord results in total
neurologic dysfunction resembling complete cord injury (spinal
Incomplete shock )

Cord  Central Cord Syndrome

Transection  Brown-Sequard Syndrome
 Anterior Spinal syndrome
 Posterior Cord Syndrom
 Cauda Equina Syndrome
 Flexion Compression injuries to the cervical spine may damage
anterior spinal artery cutting off blood to anterior 2/3rd of spinal
cord.
 Loss of motor function and sensation of pain, light touch, and
temperature below injury site
 Retain positional, and vibration sensation
 Poor prognosis

AnteriorCord
Syndrome
 Hyperextension of the cord results in pinching of the cord in pre-
existing degenerative narrowing od the spinal cord.
 Upper limbs and hands profoundly affected.
 Distal motor function in the legs usually spared.
 Fair Prognosis

CentralCord
Syndrome
  Penetrating injury that affects one side of the cord
 Ipsilateral motor loss vibration and position sense.
 Contralateral pain and temperature sensation loss
 Best prognosis

Brown-
Sequard’s
Syndrome
  Least frequent syndrome
 Injury to the posterior (dorsal) columns
 Loss of proprioception
 Pain, temperature, sensation and motor function below the level
of the lesion remain intact

PosteriorCord
Syndrome
Cauda Equina
Syndrome
Whiplash
Injury
  85% of significant spinal injuries will be seem on standard lateral
cervical spine.
 CT Scan should be obtained.
 Most Sensitive in spinal trauma.
 Complex patterns and fractures can be understood.

Diagnostic  MRI
 Best at visualizing soft-tissue elements of the spine.
Imaging  Possible to view spinal cord hemorrhage, epidural and prevertebral
hematomas.
 Not good at assessing bony structures.

 In spinal traumas radiographs and CT scans usually give sufficient

information and MRI is not required.
 Objectives
 Preserve neurological function.
 Relieve reversible nerve or cord compression.
 Stabilize the spine.
 Rehabilitate the patient.

Management  An important goal is to prevent secondary injury to the spine or

spinal cord.
of the
Spinal Injury
Patient
  In unstable injuries, flexion or extension of the spine can contuse
or transect the cord.
 Which can result in paraplegia, quadriplegia, or even death from
spinal injury.

 Immobilize spine immediately.

Pre-hospital
 A rigid collar should be used to immobilize the cervical spine.
care  Patients with thoracic or lumbar spine injuries should be shifted by
logroll technique on a flat ,firm padded back board in supine
position.
 Transfer to a trauma center Immediately.
 Pre hospital medical care should be directed at avoiding hypoxia
and hypotension, both of which can further stress the injured cord.
 1. ABC
2. Intubation if needed.
3. Spinal stabilization.
4. Secondary survey.
5. Logroll – look for bruising , palpate for step and tenderness.
6. Look for associated injuries, such as brain, thoracic, or abdominal injuries.

Emergency 7.
8.
Imaging; X-rays , CT ,MRI.
Repeated neurologic examination helps determine the presence of deficits
Department 9.
its progression /resolution.
Hypotension and bradycardia may indicate neurogenic shock.
Care 10. Maintain the systolic blood pressure at a value of at least 90 mm Hg with a
heart rate of 60-100 beats per minute.
11. Bradycardia may be treated by the use of atropine.
12. Attempt to maintain urine output at a minimum of 30 mL/h. If all of the
above parameters are difficult to maintain, consider support with inotropic
agents.
13. These patients are also at risk for hypothermia and should be warmed to
maintain a core temperature of at least 96°F. Place a Foley catheter to help
with voiding.
 With no neurological deficit:
 If stable-pain relief , collar or brace.
 If unstable-reduce and hold secure until bone / ligaments
heal with surgery or traction.
With complete sensory or motor loss:
 Usually an unstable injury
 Only consider conservative management for high thoracic
Management injuries.
 Early operative stabilization to help with nursing , prevent
spinal deformity and pain.
 Speeds up rehab.
With incomplete neurological loss:
 Stable injury-conservative bed rest , brace.
 Unstable injury-early reduction and stabilization.
  The goals of operative treatment are to
decompress the spinal cord canal and to
stabilize the disrupted vertebral column.
 Also consider the need for stabilization
procedures.
Surgical  Categories of procedures for spine stabilization
Approach  The 4 basic types of stabilization procedures are
1. posterior lumbar interspinous fusion,
2. posterior rods
3. cage
4. The Z-plate anterior thoracolumbar plating system.
Each has different advantages and disadvantages.