Assesment in Spinal Trauma

Syaifullah Asmiragani MD
Spine Section
Orthopaedic and Traumatology
Saiful Anwar Hospital / Faculty of Medicine
Brawijaya University, Malang

Medicine is a science of uncertainty

and an art of probability
Sir William Osler

Controversy in spinal trauma:

Operative vs non op
(stable, neurologic intact burst , JBJS
2015)

Early vs Late
Anterior vs posterior
Long construct vs short
contruct
Open vs percutaneous
Moussalem et al 2008, trauma AS and
DISH

Methylprednisolon yes or
no
Kypho vs vertebroplasty

How to decide ?

Torre de Pisa
Build in year of 1178
Weak foundation

Diagnosis
the most important foundation

Spinal trauma
In young adult mostly high energy trauma the
associated injuries must be considered.

In elderly bone weakening (osteoporosis,

malignancy ) , cervical stenosis result from low
energy trauma + premorbid problem

Potential Energy ( fall from height):

(Mass x gravity) x height
FxS
Kinetic energy (RTA) :
1/2 mv2

Trauma is disease
mechanical energy

of

excess

of

Tissue injury (bone and spinal cord)

inability to absorb transferred energy
thoracic fracture vs thoracolumbar fracture
need more energy in thoracic spine
associated injury >>>
ABCD more get attention in acute setting

Vertebral Column
FSU
Pararavertebral muscle

Redirection force

ANATOMYBIOMECHANIC
PATHOMECHANIC TREATMENT

MODE OF INJURY

Mode of Injury

A.
B.
C.
D.
E.
F.
G.

Axial compresion
Fleksion
Lateral compresion
Shear
Extention
Flexion distraction
Flexion Rotation

Facet
8

ANTERIOR
TRANSLATION
AXIAL LOADING
(20%)
ROTATIONAL
FORCE

INJURY
1. FACET fracture
AND
ANULUS
RUPTURE
2. TRANVERSE
Processes
fracture
Farfan 1970
Abumi 1990

Transitional Zone

SPINAL COLUMN FR. LONG BONE FR.

SPINAL CORD I NJURY PROBLEMS
Respiratory complication
Vascular complication
Gastrointestinal complication
Etc..

Identify the complication EARLIER !!!

Cause of death

Frankel , 1998

Spinal cord injury

DEFORMITY

w/out life threatening

problem

SPINAL TRAUMA
PROBLEM
Associated injury
w/out life threatening
problem

INSTABILITY
Mechanical: temporary - permanent
Neurologic : total - partial
Combined

Clinical investigation

 Associated injury (w/out life threatening

problem)
ATLS sequences
Spinal assesment
- vertebral column injury ( deformity,
pain, hematome )
- spinal cord function : motoric,
sensoric (ASIA/Frankel)
reflexes , rectal examination

Investigation

The conscious patient may

be examined in greater
detail.
Difficult to assess sensory
and motor function in the
unconscious or intoxicated
patients

Distracting injuries : injuries that are so

severely painful that the neck examination
is unreliable (The Canadian C spine rule)
USD180 million/year for c- spine imaging
NEXUS -ve predictive value : 99,6%
< 1 yo
> 65 yo

Investigation

Inspection and palpation of

the entire spine should be
performed.
Neurologic examination
Motor
Sensation,
Reflexes
Conus medullaris
Cauda equina
Rectal exam

Sacral sparing : some movement

or sensation is preserved in
the sacrum

ASIA Impairment Scale

ASIA Impairment Scale

A

Complete = No motor or sensory function is preserved

in the sacral segment S4-S5
B Incomplete = Sensory but not motor functions
preserved below the neurological level and includes
the sacral segment S4-S5
C Incomplete = Motor functions is preserved below the
neurological level and more then half key muscles
below the neurological level have a muscle grade less
than 3.
D Incomplete = Motor functions is preserved below the
neurological level and more then half key muscles
below the neurological level have a muscle grade of 3
or more.
E Normal = motor and sensory normal

Sensory incomplete tetraplegia

Pinprick sensation sparing
predicts motor recovery
85 % vs 1,3 %

Poynton 1997

Reflect proximity of
spinothalamic and corticospinal
tracts Kirshblum 1998

Direction force

ASIA A and B are different in recovery of Quality

Of Life and prognosis
Spinothalamic tract just few millimeters anterior to
Corticospinal tract

Neurological improvement after

admission
(complete vs incomplete)
11 % A improved ,
3% to grade D/E

44% B improved ,
28 % to grade D/E, 5% worsened

55% C improved
3 % worsened

97% D/E remain D/E

2% worsened

- Wide variety in prognosis between ASIA A and B

- Neurological recover functional recovery
- Bladder sexual function pain motoric
power

imaging

Imaging
Plain x ray
To establish diagnoses and
configuration of fracture
To asses malalignment ( kyphosis,
scoliosis, dislocation/sublux )
To asses instability
- loss of body height
- cobb angle
- anterior translation
- posterior ligamentous
injury (indirect)

Imaging
CONVENTIONAL
RADIOGRAPH
STATIC X-ray
SUPINE
VS
WEIGHT
BEARING (Mehta 2004)
- Change treatment in 25%
base on erect film
- Elderly vs young

SUPINE
ABCS
Alignment 4 line
Bone
body, facet,
spinosus process
Cartilage
Soft Tissue
Instability
50 % body collapse
20 degree kyphosis

Imaging

THE FACT
CONVENTIONAL RADIOGRAPH
low sensitivity 52% - 85 %, 17% unstable fracture unidentified
flexion-extention x ray
acute setting
are not effective, associated risk
sub acute
effective
good for dislocation or sublux but not for fracture

Computed Tomography
Configuration of fracture
Canal encroachment (1,25mm slice thickness)
To detect additional spine injury
To detect malalignment
Integrity posterior wall of vertebral body
(vertebroplasty)
Other spinal pathology (ankylosing)
Disadvantage radiation induced malignancy

Imaging
The Fact :
CT Scan
1st line imaging modality
only 0,7% were missed , and these fractures requiring minimal
or no treatment
disadvantage : high cost and radiation exposure

MRI

MRI
To asses the spinal cord injury, disc
herniation
To detect the posterior ligamentous
injury (T2 weighted)
To detect other spinal pathology

Imaging

MRI
soft tissue injury ( ligamentous injury, spinal cord injury )
primary indication presence of neurological deficit
sensitive in 24-72 hrs
Limitation :
time consuming pts w/ potential hemodynamic
instability
presence of traction (titanium?), ventilators
lack of 24 hrs aviability

Conventional Radiograph, CT and MRI

sensitivity : 97,2 %
specificity : 98,5 %
negative predictive value : 100%

Imaging
Conventional Radiograph, CT and MRI
sensitivity : 97,2 %
specificity : 98,5 %
negative predictive value : 100%
PRADUGA BERSALAH !

DEFORMITY

SPINAL Collumn
PROBLEM
INSTABILITY
Mechanical: temporary - permanent
Neurologic : total - partial
Combined

Trauma Deformity Imbalance

kyphosis/scoliosis

Conus of economic Global spinal balance

30

Spinal Instability
Instability :
loss of normal relationship between anatomic structures with
a resulting alteration of natural function

Spine can no longer carry normal load

Permanent deformity may occur resulting in severe pain
Potential for cathastrophic neurological injury

Classification
Dennis : Morphology

x-ray and CT
Scan
AO
: MOI

x-ray and CT
Scan
TLICS : x-ray , CT
MRI
Physical Exam

Clinical decision is not imaging based

decision
Mark B Dekutoski

Seorang pasien masih mendapatkan manfaat

saat dioperasi dengan tehnik yg tidak sempurna
namun dengan indikasi yang tepat, daripada
dioperasi dengan tehnik yang sempurna namun
indikasinya salah !!!

TERIMAKASIH