SPINAL TRAUMA

Dr Gerry Maxmillan Pang

Orthopaedic & Traumatology Surgeon
Queen Elizabeth Hospital

Basic Considerations

Injury to the spinal column can be devastating

Neurologic deficit occurs in 10 to 25 percent of
patients at all levels of injury

40 percent at cervical spine levels

15 to 20 percent at thoracolumbar levels

Cost to society per patient remains staggering

Minimize the risk of further damage by using
accepted techniques of initial transportation and
treatment

Causes of spinal column and spinal cord injury

When a neurologic deficit is associated with

spinal column injury, the overall survival rate for
all levels of injury is 86 percent at 10 years
In patients older than 55 years, in quadriplegics,
the leading cause of death is pneumonia
Accidents and suicides are most common in
those younger than 55 years of age, in
paraplegics

Vertebral Anatomy

33 Vertebrae in human

7 Cervical vertebrae

12 Thoracic vertebrae

5 Lumbar vertebrae

5 Sacral fused vertebrae

4 Coccyx fused vertebrae

Atlas (C1) and Axix (C2), are the vertebrae that allow the
neck and head so much movement

Atlanto-occipital joint
Atlanto-axial joint

Cervical

The atlanto-occipital joint allows the skull to

move up and down
The atlanto-axial joint allows the upper neck
to twist left and right
The axis also sits upon the first intervertebral
disk of the spinal column
Smallest, lightest vertebrae and the vertebral
foramina are triangular in shape
Bifid spinous process (except C7)

Thoracic

Transverse processes have surfaces that

articulate with the ribs

Some rotation can occur between the

thoracic vertebrae, but their connection with
the rib cage prevents much flexion or other
excursion

Lumbar

Robust in construction, as they must support

more weight than other vertebrae

Allow significant flexion, extension and

moderate lateral flexion (sidebending)

Sacral & Coccyx

Fused in maturity with no intervertebral discs

Spinal Cord Anatomy

Spinal cord fills about 35 percent of the canal at the

level of the atlas and then about 50 percent in the
cervical and thoracolumbar segments

Remainder - cerebrospinal fluid, epidural fat,

and dura mater

Myelomere - segment of cord from which a nerve root

arises
Myelomeres in the cervical and high thoracic lies one
level above the same-numbered vertebral body
Lumbar and sacral myelomeres are concentrated
between the T11 and L1 vertebral bodies

The end of the spinal cord (i.e., the conus medullaris)

is most commonly located at the level of the L1-L2
intervertebral disk
The conus medullaris consists of the myelomeres of
the five sacral nerve roots

Spinal Cord Injury

Primary injury occurs at the moment of impact to the

spine

(1) Direct injury by means of excessive flexion,

extension, or rotation of the spinal cord

(2) Dndirect injury by impaction of displaced

bone or disk material

Secondary injury to the spinal cord occurs after the

initial direct injury to neural tissue

Complicated

Chemical, cellular, and tissue level

Not completely understood

Cell death can occur as a

result of necrosis or
apoptosis

cellular swelling

damage to
mitochondrial and
membrane

Eventually leads to
cavitation

Classification of Neurologic Injury

Evaluation to determine the extent of neurologic deficit in a

patient with spinal cord injury
Incomplete neurologic deficit

Complete injuries in the first 24 hours

Good prognosis for at least some functional motor

recovery,
3% functional motor recovery

Complete injuries after 24-48 hours

Never

American Spinal Injury Association (ASIA)

Complete injury

Incomplete injury

no motor and/or sensory function exists more

than three segments below the neurological level
of injury
some neurologic function exists more than three
segments below the level of injury

Critical to this determination is the definition of level of

injury
Most caudal segment that tests intact for motor and
sensory functions on both sides of the body

Sacral Sparing

Incomplete spinal cord injury

at least partial structural continuity of the white

matter long tracts (i.e., corticospinal and
spinothalamic tracts)

Continued function of the sacral lower motor neurons in the

conus medullaris and their connections through the spinal
cord to the cerebral cortex
Potential for more function after the resolution of spinal
shock
Documentation of its presence or absence is essential

Sacral sparing is demonstrated by

Perianal sensation

Rectal motor
function

Great toe flexor activity

Spinal Shock

State of complete spinal areflexia after a severe spinal

cord injury

last for a varying length of time

classically evaluated by testing the

bulbocavernosus reflex (spinal reflex)

frequently absent for the first 4 to 6 hours after

injury but usually returns within 24 hours

99% of patients emerge from spinal shock - present of

bulbocavernous reflex

Spinal Shock

State of complete spinal areflexia after a severe spinal

cord injury

last for a varying length of time

classically evaluated by testing the

bulbocavernosus reflex (spinal reflex)

frequently absent for the first 4 to 6 hours after

injury but usually returns within 24 hours

99% of patients emerge from spinal shock - present of

bulbocavernous reflex

Bulbocavernosus Reflex

Present Bulbocavernosus reflex

No spinal cord fuction
Absent sacral sparing

Injury is termed COMPLETE

99 percent of patients with complete injuries will have

no functional recovery

!! exception - direct injury to the conus medullaris can

disrupt the bulbocavernosus reflex arc

Classification System

Incomplete Spinal Cord Injury Syndrome

Incomplete
Cord
Syndromes
Syndrome

Frequency

Functional
Recovery (%)

Description

Central

Most common

Usually quadriplegic, with sacral sparing; upper extremities affected more than
lower

75

Anterior

Common

Complete motor deficit; trunk and lower extremity deep pressure and
proprioception preserved

10

Posterior

Rare

Loss of deep pressure, deep pain, and proprioception

Brown-Squard

Uncommon

Ipsilateral motor deficit; contralateral pain and temperature deficit

>90

Root

Common

Motor and sensory deficit in dermatomal distribution

30100

Management
Accident Scene Management

Initial evaluation of any trauma patient begins at the

scene
Advanced trauma life support (ATLS) method
described by the American College of Surgeons

A (airway),

B (breathing), and

C (circulation and cervical spine).

A spinal column injury should be considered in all

polytrauma patients

unconscious

intoxicated

head and neck injuries

Organized extrication and transport plan can be developed

to minimize further injury to neural tissue

Regardless of the position in which found, the patient

should be placed in a neutral spine position with respect
to the long axis of the body
An emergency two-piece cervical collar is then applied
before extrication from the accident scene
A scoop-style stretcher is now recommended for transfer
Placed on a rigid full-length backboard and secured with
sandbags on either side of the head and neck and the
forehead taped to the backboard

Scoop stretcher

Management
Resuscitation

Hemorrhage + Hypovolemia = Hypotension

Syndrome of neurogenic shock

cervical and high thoracic spinal cord injuries

vascular hypotension plus bradycardia

occurring as a result of spinal injury

traumatic disruption of sympathetic outflow (T1L2) and to unopposed vagal tone

Hypotension needs to be aggressively treated by

blood and volume replacement

emergency surgery for life-threatening

hemorrhage

Initial treatment of neurogenic shock is volume

replacement, followed by vasopressors if hypotension
without tachycardia persists despite volume expansion

Assessment at the Emergency Dept

Rapid assessment of life-threatening conditions

Emergency treatment if required

Secondary survey

evaluation of spinal column

spinal cord function

Starts with a physical examination, with a more detailed

history elicited later

Lateral cervical spine radiograph

(occiput to the superior end plate of T1)

Unconscious or intoxicated patient

Careful observation of spontaneous extremity motion

Response to noxious stimuli and the patient's reflexes
and rectal tone can provide some information on the
status of the cord
Log-rolled onto their side with the cervical spine
immobilized

deformity, abrasions, and ecchymosis

stepoff or interspinous widening

A responsive patient who is hemodynamically stable, upper

and lower extremities are examined for motor function by
nerve root level

Imaging and injury Description

After the initial cross-table lateral cervical spine

radiograph, a complete cervical spine series should be
obtained

cross-table lateral view

anteroposterior view
open-mouth odontoid view

Computed tomographic (CT) scan through the C7 to T1

levels can rule out significant cervicothoracic junction
injuries

Cervical
spine
anterior vertebral margins

posterior vertebral margins

spinolaminar junction lines

The anterior atlantodental space

(curved white arrow) should
measure 2.5 to 3 mm or less.

Physiologic subluxation

Unilateral facet dislocation

Thoraco lumbar spine

AP view

Coronal alignment for interpedicular

distance
Space between spinous processes
translational deformity

Lateral view

Sagittal plane malalignment(cobb

method)
Vertebral body height loss
Sagittal translation deformity
Segmental kyphosis (>30 degree)

CT Scan

Plain films understimate the extent of

canal compromise by > 20%
Degree of canal compromise from
retropulsed fragments
Accurate assessment of degree of
body communition
Can detect lamina, facets, pedicle,
transverse process #

CT Scan modalities

MRI

Superior visualization of the spinal

cord and soft tissues
Important tool in assessment
integrity of PLL & PLC

MRI modalities

Classification

Denis 3 column theory of spinal instability

 McAfee Classification
based on the failure mode of the
middle osteoligamentous complex
The six injury patterns are the
following:
1. Wedge-compression fracture
2. Stable burst fracture
3. Unstable burst fracture
4. Chance fracture
5. Flexion-distraction injury
6. Translational injuries

Mc Cormacks
Classification

up to 6 points
posterior approach

7 or more points
anterior and posterior approach

Nonsurgical management of
stable TL. burst #

No PLC injury without neurologic

deficit (MRI)
25 to 30 degrees of kyphosis
< 50% height loss
Absence of interspinous process
widening
< 50% canal compromise

Spinal Orthosis

External immobilization of the spine in order to treat a

number of spinal disorders or simply protect the spine or
spinal cord
Indications for use include immobilization to allow for
fracture healing, diminish nerve root irritation, decrease
pain or weakness, and prevent deformity

Cervical Traction

(1) reduction of cervical spine deformity

(2) indirect decompression of traumatized neural

elements

(3) cervical spine stability

Spinal Orthosis

Indication of surgery

Malalignment
Instability
Progressive neurological deficit
Nonunion
Cauda equina syndrome

Timing of surgery

Controversial
Emergency decompression is
indicated:

progressive neurological deficit

neurologically normal with unstable spinal
injuries

Complete or static incomplete SCI

can delay surgery for several days to allow

resolution of cord edema

Campbell's Operative Orthopaedics, 11th ed. 1813-14. 2007

No conclusive evidence
in the literature

Early surgical decompression and

stabilization improve neurological
recovery, or
Neurological recovery is compromised
by a delay of several days
Schinkel, christian. The timing of spinal stabilization n poly trauma
and in patients with spinal cord injury. Current opinion in critical
care.14(6):685-89,Dec 2008.

Operative treatment
Loss of
body height
>50%

Focal
kyphosis
>25- 30
degrees

Instability
and higher
likelihood of
deformity
progression

Neurologic
al deficit
with a burst
#

Evidence
of PLC
disruption

Posterior surgery

To correct kyphosis and stabilize the

spine (not for decompression)
Thoracic injuries with a true complete
SCI
Injuries at the T3 and T4 level
PLC disruption with intact neurology
Lamina # ( dura tear, nerve root
entrapment)
Bucholz, Robert W.; Heckman, Rockwood & Green's Fractures in Adults,vol.
one, 1544-77, 2006.

- > 50% height loss or extensive

comminution (two levels above and
below the #)
- <50% height loss (short-segment
stabilization)

Anterior surgery

Thoracic # with an incomplete spinal

cord injury
Thoracolumbar # with any neurologic
deficit
severe kyphosis > 70% to 80% height
loss
Severely comminuted #

Combined surgery

primary post. approach

2nd stage anterior stabilization:
-new or persistent neurologic deficit
-residual canal compromise from
retropulsed bony fragments
-progressive loss of correction

primary ant. approach ,

2nd stage post.
stabilization :
-Persistence residual post. element
gapping with substantial coronal or
kyphotic deformity
-neurologic deficit associated with a
lamina # (?entrapped nerve roots)
- senile osteoporotic burst #

clinical and radiographic outcomes Efficacy of posterior

fixation without fusion was compared with that of
fusion with short-segment pedicle screw fixation

Prospective, randomized, controlled

(Jan 2000 and Dec 2002)
single-level Denis type-B (superior end plate)
burst # (T11 to L2)
average of 3.7 days from trauma
minimum duration of follow-up of five years
load sharing score of <6
Li-Yang Dai, Lei-Sheng Jiang. POSTERIOR SHORT-SEGMENT FIXATION WITH OR WITHOUT
FUSION FOR THORACOLUMBAR BURST FRACTURESJ Bone Joint Surg Am.vol 91-A, no.5
2009;91:1033-41

No significant difference in
radiographic or clinical outcomes in
two techniques
significantly less blood loss in the
nonfusion group
donor-site pain in the fusion group
loss of kyphosis correction was not
significantly different

Posterolateral bone-grafting is not

necessary short-segment pedicle
screw fixation.
( Denis type-B burst # and loadsharing score of <6)
Li-Yang Dai, Lei-Sheng Jiang. POSTERIOR SHORT-SEGMENT FIXATION WITH
OR WITHOUT FUSION FOR THORACOLUMBAR BURST FRACTURESJ Bone
Joint Surg Am.vol 91-A, no.5 2009;91:1033-41

38 pt (2002 to 2005) with TL unstable burst #

- transpedicular, balloon-assisted # reduction
- calcium phosphate bone cement reconstruction
- short-segment spinal instrumentation

Rex A.W.Marco, Thoracolumbar Burst Fractures Treated with Posterior Decompression and
Pedicle Screw Instrumentation Supplemented with Balloon-Assisted Vertebroplasty and
Calcium Phosphate Reconstruction. J Bone Joint Surg Am. 2009;91:20-8.

Improvement
Frankel grade & Oswestry scale
mean kyphotic angulation
( from 17_ preoperatively to 7)
vertebral body height
( 42% preoperatively to 14% at the
time of the latest f/u)

excellent reduction of unstable TL burst #

Ant. column reconstruction
Ant. and post. spinal stabilization with a
single incision
low rate of instrumentation failure and loss
of correction
Rex A.W.Marco, Thoracolumbar Burst Fractures Treated with Posterior
Decompression and Pedicle Screw Instrumentation Supplemented with
Balloon-Assisted Vertebroplasty and Calcium Phosphate Reconstruction. J
Bone Joint Surg Am. 2009;91:20-8.

THANK YOU