Spinal Trauma
Outline
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Incidence
Types
Clinical signs
Radiological signs
Spinal shock
Management
Incidence
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10 - 15 per million
18 - 35 years
Male - 3:1
RTA 51% - cars
Domestic 16%
Industrial 11%
Sports 16% - diving incidents
Self harm 5%
Types
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Cervical 40%
Thoracic 10%
Lumbar 3%
Dorso lumbar 35%
Any 14%
Anatomy
• Spinal cord ends below lower border of L1
• Cauda equina is below L1
• Mid dorsal spinal cord & neural canal space are of
same diameter hence prone for complete lesion
• Mechanical injury - early ischaemia, cord edema cord necrosis
• Neurological recovery unpredictable in cauda equina
ie. peripheral nerves
Cervical spine anatomy
• 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.
Significance
• Unstable if middle column + either Anterior or
Posterior column is damaged
• Rupture of interspinous ligament is :
- associated with avulsion of spinous process
- Unstable spine
- Further flexion increases neurological injury
Level of Spinal injury
• Neurological level is at the most lowest segment with
normal motor & sensory function
• Difficult to determine :
- as most muscle efferents receive fibres from more
than one level
- Closed cord lesions may extend over several cms.
- Dermatomes have imprecise boundaries.
Cord level
• C2 – C7 = add +1 for cord level
• T1 – T6 = add +2
• T7 – T9 = add +3
• T10 = L1, L2 level
• T11 = L3, L4 level
• L1 = sacro coccygeal segments
Degrees of injury
• Complete - flaccid paralysis + total loss of sensory &
motor functions
• Incomplete - mixed loss
- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome
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.
Types of bony injury
• Flexion
• Extension
• Flexion with rotation
• Compression
Pathophysiology
• Primary Neurological damage
Direct trauma, haematoma & SCIWORA < 8yrs old
In 4hrs - Infarction of white matter occurs
In 8hrs - Infarction of grey matter and irreversible paralysis
• Secondary damage
Hypoxia
Hypoperfusion
Neurogenic shock
Spinal shock
Hypoxia
• Lesions above C5 – damage to diaphragm leads to 20%
reduction in vital capacity Rx Phrenic n. pacing
• Lesions at D4-6 – reduces vital capacity if < 500ml patient is
ventilated
• Intercostal nerve paralysis
• Atelectasis – poor cough
• V/Q mismatch
• Reduced compliance of lung – muscle fatigue.
Neurogenic shock
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Lesions above D6
Minutes – hours (fall of catecholamines may take 24 hrs)
Disruption of sympathetic outflow from D1 - L2
Unapposed vagal tone
Peripheral vasodilatation
Hypotension, Bradycardia & Hypothermia
• BUT consider haemmorhagic shock if – injury below D6,
other major injuries, hypotension with spinal fracture alone
without neurological injury.
Spinal shock
• Transient physiological reflex depression of cord function –
‘concussion of spinal cord’
• Loss anal tone, reflexes, autonomic control within 24-72hr
• Flaccid paralysis bladder & bowel and sustained Priapism
• Lasts even days till reflex neural arcs below the level recovers.
Assessment & Managemnt
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Failure to suspect leads to failure to detect injuries
ABCDE – Logroll and remove the spinal board
Look for markers of spinal injury
Secondary survey
Adequate Xray’s
Emergency treatment
Surgery
Definitive care & rehab.
Clinical features
• Pain in the neck or back radiating due to nerve root
irritation
• Sensory disturbance distal to neurological level
• Weakness or flaccid paralysis below the level
Signs in an Unconcious patients
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Diaphragmatic breathing
Neurological shock (Low BP & HR)
Spinal shock - Flaccid areflexia
Flexed upper limbs (loss of extensor innervation
below C5)
• Responds to pain above the clavicle only
• Priapism – may be incomplete.
Signs of spinal injury
• Forehead wounds – think of hyperextension injury
• Localized bruise
• Deformities of spine - Gibbus, feel a step & Priapism
• Beevors sign – tensing the abdomen umbilicus moves
upwards in D10 lesions
Prehospital transfer
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Awareness of the crew & by A&E staff
Modified left lateral position at scene
Kendrick or Russell’s extrication device
Scoop stretcher slotted together around the patient
Agitated patient left alone with hard collar
Repeated assessment enroute
Head down if they vomit
Remove objects from clothes to avoid pressure sores
Avoid opiates in high lesions
Avoid oral suction in tetraplegics – vagal reflex
Care in A&E
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Careful manual handling especially if unconcious
Jaw thrust is safer
Correct gross spinal deformities
Call the anaesthetist if diaphragmatic paralysis or RR>35
Use flexible fibreoptic scopes in unstable fractures
Ryles tube if abdominal distension causes respiratory probl
Cathetrize to avoid overstretching of detrusor
IV fluids – paralytic ileus in first 48hrs.
Passive movements to rule out fractures
Small iv doses of opiates
Assessment
• Document the level of injury
• Rule out other injuries – DPL in abdominal injuries as there is
paralytic ileus and absent peritioneal irritation.
• Associated injuries in dorsal spine fracture are :
- Renal injuries
- Chest and Sternal injuries
- Wide Mediatinum due to fracture haematoma.
- Retroperitoneal injuries
Radiology
• Be thorough – Adequacy, Alignment,Bones, Cartilages and
soft tissues and distances
• SCIWORA in kids
• Low threshold for xray in rheumatoid & Ankylosing spond
• Flexion injury common in lower cervical spine
• Extension injury in upper cervical Spine
• Junction of mobile & fixed part are prone to injury eg. C7
T1 & D12 L1.
Radiographs in spinal injuries
• Lateral C spine views in diagnostic in 80%
• Complete set of C spine xray are 90% diagnostic
• CT of the c spine is 98% diagnostic
• 22.5* logrolled view for better views of the facets
• 45* view shows the intervertebral foramen & facets
Normal Cervical Spine
• Peg & lateral mass distance <2mm and symmetrical
• Peg & arch of atlas distance <2mm in adults < 4mm in kids
• Above C4 the width is <half of the VB width below C4 its
equal to one VB width
• Pseudosubluxation of C2 on C3 is normal in young kids& it
disappears on extension
• C1 and C2 interspinous space <10mm wide
• Distance between occiput and atlas <5mm
• Anterior compression of VB >40% suggest burst fracture
Abnormal C spine
• Unilateral facet dislocation < half of the vertebral body
shifted on the lateral view
• Bilateral facet dislocation > half shifted forwards
• Wide interspinous gap is unstable (crush fracture or
subluxation) suggestive of rupture of the posterior cervical
ligament rupture and haematoma formation.
• Severe flexion injury – fractures the anteroinferior margin
of the vertebral body
• Severe extension injury – fractures the anterosuperior
margin of the VB.
Emergency treatment
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ABCDE
Keep warm
Treat if BP<80mmHg & HR <50bpm
Spring loaded gardener wells calipers for traction
H2 Antagonists & Heparin
• Methylprednisolone 30mg/kg iv bolus over 15min
immediately
• 45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in
first 3 hours after the injury.
• 5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.
Whiplash injury
• Sudden hyperextension and flexion
• Increasing neck pain for the first 24hours
• Associated headache, pain radiating to both shoulders and
paraesthesia in hands
• Reduced lateral flexion
• Anterior longitudinal ligaments are torn causes dysphagia
• Forward flexion against resistance is painful
• 90% are asymptomatic after 2years
• 10% still have pain
• Some still claim money hence the need for proper
documentations.