Spine Trauma

Yudha Mathan Sakti

Departement of Orthopaedic and

Traumatology
RS DR Sardjito FK UGM
It is important !
 Incidence
It is estimated that 12,000 new cases of spinal cord injury / year in US

Male patients, 81% Male - 3:1

Average age of spinal cord injury in US was 37,6 years

Patients with a spinal cord injury, the overall mortality during the initial
hospitalization is 17%.

Approximately 2% to 6% of trauma patients sustain a cervical spine fracture.

The leading cases of spinal cord injury are :

Vehicular accidents (45%)
Falls from height (15%)
Act of violence (15%)
Sport related injuries (15%)
Miscellaneous causes (5%)
 Goals
1. Safe extrication and transport

2. ATLS

3. Accurate identification and classification of spinal injury

4. Identification of associated injuries (head, pulmonary,

abdominal, other bone injuries)

5. Stabilization of unstable spinal segments

6. Early transport to an appropiate acute spinal cord

rehabilitation center
 Important aspect of prehospital care
of the potentially spine-injured patient

High-energy mechanism
Injury above the clavicle
Fall from height
Pain in the spine following trauma
Neurologic compromised
Unconcious

Should be considered to have spine injury

until proven otherwise
1. Safe extrication and transport

Neutral in-line position

with manual in-line immobilization
2. Do the ATLS
 Delayed diagnosis of vertebral injury is frequently associated with
loss of consciousness secondary to multiple trauma or
intoxication with alcohol or drugs.
GENERAL EXAMINATION SHOCK
Hypovolaemic shock is suggested by tachycardia,
peripheral shutdown and, in later stages, hypotension.

Neurogenic shock distributive shock reflects loss of

the sympathetic pathways in the spinal cord
hypotension, bradycardia

Spinal shock occurs when the spinal cord fails

temporarily following injury Below the level of the
injury, the muscles are flaccid, the reflexes absent and
sensation is lost
3. Accurate identification and classification
of spinal injury
 Look and Feel

The spine must be

protected.

Logroll the patient

Examine the skin for

bruising and
abrasions, Palpate
spinous processes for
tenderness and
diastasis.

Evaluate neurologic
condition
 Mechanism of injury

Direct injury
Penetrating injuries ( knives, firearms )

Indirect injury
Axial compression
Flexion
Lateral compression
Flexion-rotation
Shear,
Flexion-distraction and extension
Evaluate neurologic condition
Evaluate neurologic condition 10 only
Evaluate neurologic condition 10 only
Evaluate neurologic condition 10 only
 Spinal cord injury

Complete - flaccid paralysis + total loss of sensory

& motor functions

Incomplete
- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequards syndrome
- Cauda equina syndrome
 Confirm the Spine Assessment

lateral cervical spine radiograph is routine in the standard

evaluation of trauma patients

Radiographic examination of the entire spine is

recommended in patients with spine fractures when complete
clinical assessment is impaired by neurologic injury

CT and MRI for subtle or deeper investigation

MRI vs CT Scan
 Fractures of the Thoracolumbar Spine

Most benign compression

fractures
(< 20o kyphosis, < 50% canal
compromise & neurologically
intact)
Neurologic injury complicates
15% to 20% of fracture at the
thoracolumbar level
65% due to MVA

Managed symptomatically
Activity modification & bracing
 Spine Stability
Anterior column - Anterior
longitudinal ligament+ Anterior
annular ligament and anterior
half of VB.

Middle column Posterior long.

Lig. + Posterior annular ligament
+Posterior half of VB.

Posterior Column Lig flavum +

superior & Interspinous lig +
intertransverse capsular lig +
neural arch + pedicle & spinous
process.
Three column model by denis the lession is considered unstable
if 2 or more column are involved
 Subaxial cervical spine trauma classification
(SLIC system)

Morphology Disco-ligamentous Neurological status

complex
No abnormality Intact 0
0 Intact 0 Complete cord injury 1
Compression 1 Intermediate Incomplete cord injury 2
Burst +1-2 1 Continous cord compression +1
Distraction Disrupted
3 2
Rotation/tranlstion 4
 Treatment
SLIC =4
SLIC >= 5
SLIC <=3 Consider for
operative Operative
Non-operative treatment
treatment or
treatment
non operative
treatment
4. Identification of associated injuries (head, pulmonary,
abdominal, other bone injuries)

Calcaneus fracture
 Management

General condition The Spine The Neurologic function

 Patients with no neurological injury

Stabilize the injuries

the patient is treated by supporting the spine in a
position firm collar or lumbar brace until soft
tissue healed and pain and muscle spasm subside.

Patients with neurological injury

spinal injury is stable conservatively and rehabilitated as soon
as possible

unstable injury conservative treatment operative

stabilization
 Indications for surgical stabilization
an unstable fracture with
progressive neurological
deficit and MRI signs of
likely further neurological
deterioration; and

an unstable fracture in a
patient with multiple
injuries.

Refer to the TLICS Score

Non Operative treatment
Non Operative treatment
 Pharmacologic Treatment
of Spinal Cord Injury
Methylprednisolone:
decreasing lipid peroxidation
stabilizing cell membranes
enhancing spinal cord blood flow
decreasing vascular permeability & edema

National Acute Spinal Cord injury Study (NASCIS) II trials:

methylprednisolone (within 8 hours): significantly better neurologic
recovery
after 8 hours: worst outcome (relatively high rate of complications)

Dosage:
30 mg/kg of IV methylprednisolone (for 1 h); followed by 5.4 mg/kg
(administered over the next 23 h); if administered within 3 h of injury
when is initiated 3 to 8 h after injury: maintained for 48 h
^-^ Thank you
 Significance
Unstable if middle column + either Anterior or
Posterior column is damaged

Rupture of interspinous ligament are :

- associated with avulsion of spinous process
- Unstable spine
- Further flexion increases neurological injury
 Pathophysiology
Primary changes
Physical injury may be limited
The spinal cord and/or nerve roots may be
injured, either by the initial trauma or by ongoing
structural instability
Secondary changes
During the hours and days following a spinal
injury
PRINCIPLES OF DIAGNOSIS
 Cervical injury
Mechanism of injury
Cervical clearance
Neurogical examination
Radiological examination
Cervical Injury Classification
Initial management
 Mechanism of injury

(a) a fall onto the head or the back of the neck; and (b) a blow on
the forehead, which forces the neck into hyperextension.
 Cervical clearance of spine injury
- Fully alert and orientated
- No head injury
- No drugs or alcohol
- No neck pain
- No abnormal neurology
- No abnormal neurology
- No significant other distract
 Examination

Neck
supporting his or her head with their hands
Inspected : deformity, bruising,
penetrating injury
Palpated : tenderness and areas of
bogginess, or increased space between the
spinous processes, suggesting instability due
to posterior column failure
ASIA Motor and Sensory Testing
 Trauma Series Films
Lateral c-spine
Hi specificity/ low
sensitivity; Need 3 view
c-spine series !!
Visualize junctions
Parallel lines
Pre-vertebral STS
 Secondary Radiographic Studies

MRI
Improving
Dynamic Ro--rarely
applicable in acute setting
CAT Scan
Most common 20 study
Great bony detail
Reconstructions
 Cervical Spine Injury Severity Score
(CSISS)
the physician in grading the severity of
injuries,
determining the prognosis,
facilitating communication with other
physicians,
developing effective management strategies
 cervical spine is divided
into four columns:
anterior,
posterior,
right pillar (right lateral
column),
left pillar (left lateral
column)
 Each column is scored on an analog scale
ranging from 0 to 5 point higher values
more severe injuries as judged on the basis of
bone and ligamentous disruption
the total ranging from 0 to 20 points
 INITIAL MANAGEMENT
General support
resuscitation protocol (airway with cervical spine
control, breathing, circulation and haemorrhage
control) supersedes the assessment of the spinal
injury
Adequate oxygenation, ventilation and circulation
will minimize secondary spinal cord injury
 Emergency physician + trauma team
evaluate and begin the treatment of all
injuries
Glasgow Coma Scale is frequently utilized to
assess neurogical status
Conscious patient
Unconscious patient difficult
 TREATMENT METHODS
In-line immobilization
Semirigid collars
Rigid collars
Tongs
Halo ring
Fixation
Sacral sparing
Preservation of active great toe flexion, active anal
squeeze (on digital examination) and intact peri-anal
sensation

Anal wink (S3-5) Bulbocav reflex (shock)

 NEUROLOGICAL EXAMINATION
Cord longitudinal column functions
corticospinal tract (posterolateral cord, ipsilateral
motor power), spinothalamic tract (anterolateral
cord, contralateral pain and temperature) and
posterior columns (ipsilateral proprioception).
Methods of temporary immobilization
QUADRUPLE IMMOBILIZATION
A backboard, sandbags, a forehead tape and a
semirigid collar are applied.
If the back is to be examined

logrolling technique
 Anterior spinal cord syndrome
Flexion rotational force to spine

Due to compression fracture of

vertebral body or anterior
dislocation

Anterior spinal artery

compression

Loss of power, reduced pain and

temperature below the lesion.
 Posterior cord syndrome
Hyperextension
injuries

Posterior vertebral
body fracture

Loss of
proprioception and
vibration sense

Severe ataxia
 Central cord syndrome
Older age with cervical
spondylosis
Hyperextension with minor
trauma

Cord is compressed by
osteophytes from vertebral body
against thick ligamentum
flavum.

Damages the central cervical

tract

UMN lesion to legs (spastic)

LMN to arms (flaccid paralysis)
 Brown sequards syndrome
Hemisection of the cord

Stab injury and lateral

mass fractures

Uninjured side has good

power but absent pinprick
and temperature.

Spinothalamic tracts cross

to opposite side of the cord
three segments below.