Chapter 33 Spinal injuries
鍾耀文 / 李芳年, 2000 年 12 月 27 日
Historical perspective
¤ Hunched vs upright posture.
¤ 1 gm weight dropped from a height of only 10 cm on to a monkey’s
surgically exposed spinal cord result in permanent neurologic dysfunction.
Epidemiology
¤ Automobile and motorcycle accidents : 1/2 spinal injuries
¤ Falls 20%, sporting activities 15%,
intentional acts of human violence 15%
¤ Arthritic disease, malignancy, osteoporosis in the elderly
¤ Median age 25 y/o, men to women: 4 to 1
Pathophysiology
¤ Spinal column injury
Normal anatomy:
33 bony vertebrae: 7C 12T 5L 5S(1) 4C(1) Fig 33-1 p463
2 columns Fig 33-2 p465
Riggins and Kraus vertebral injuries :14% spinal cord injuries
Various types of vertebral injuries Table 33-1 p466
Hardy’s report: 141 to 384 ( 37 % ), evidence of neurologic deficit
No radiographically demonstrable vertebral injuries
¤ Classification of spinal injuries : Table 33-2 p466
1. Flexion
Simple wedge fracture: stable, rarely NS damage Fig 33-3 p 467
Teardrop fracture: ligamentous injuries, may NS Fig 33-4 p467
Clay shoveler’s fracture: oblique fracture of the base of the
spinous process of one of the lower cervical segments, Fig 33-5
p468 ( avulsion fracture ), direct trauma-pool cues, baseball bats,
Sudden deceleration, Stable, no NS
Subluxation: ligamentous complexes rupture without bony
injuries, widening of the interspinous space and gaping of the
intervertebral space posteriorly, potentially unstable, rarely NS
Fig 33-6 p469
Bilateral facet dislocation: high incidence of spinal cord injury,
extremely unstable condition, soft tissue disruption, the
displacement is greater than 1/2 AP diameter of the lower vertebral
body, Fig 33-7 p470
1
Atlantooccipital or atlantoaxial joint dislocation:
With or without an associate fracture of the odontoid
Unstable( lack of muscle and ligamentous support )
Fig 33-8 p470
Lateral displacement of the odontoid: unstable Fig33-9
Fracture through the transverse process: stable p471
2. Flexion-rotation
Unilateral facet dislocation: fulcrum, contralateral dislocate
rest within the intervertebral foramen, locked in place-stable
less than 1/2 AP diameter, Fig33-10 p472, oblique projections
bow tie deformity
C1-C2 level---Rotary atlantoaxial dislocation: unstable
asymmetry between odontoid process and lateral masses of C1
Fig 33-11 p474
Thoracolumbar and lumbar region: unstable, Fig 33-12 p474
3. Extension
Posterior neural arch fracture of the atlas: compression
posterior elements- occiput and the heavy spinous process of the
axis, Fig 33-13 p475, potentially unstable
Hangman fracture or traumatic spondylolysis of C2:
cervicocranium, bilateral fractures of the pedicles of the axis
occur with or without dislocation, Fig 33-14 p476, unstable, cord
damage minimal, neural canal is greatest at the C2, death from
hanging commonly resulted from strangulation rather than cord
damage.
Extension teardrop fracture: Axis, triangular-shaped
fracture, Fig 33-15 p476, C5 and C7—diving accidents—central
cord syndrome-ligamentum flavum buckles into.
4. Vertical compression
Burst fracture, Fig 33-16 p477, stable, impinge on or
penetrate the ventral surface of the spinal Cord
The Jefferson fracture of C1: occipital condyles to atlas
Fracture of the Ant. and Post. arches of the atlas and a disruption
of the transverse ligment, widening of the predental space( adults
3 mm, children 5mm), prevertebral hemorrhage, Fig 33-17 p478
Extremely unstable
Isolated fracture of the articular pillar or the vertebral body:
Fig 33-18 p479
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¤ Spinal cord injury
Primary spinal cord injury
Penetrating trauma or massive blunt trauma
Elderly patients with cervical osteoarthritis and spondylosis,
Fig 33-19 p479
Primary vascular damage to the spinal cord: extradural hematoma
Bleeding disorders, undergoing anticoagulation therapy
Felty’s syndrome, Epidural hematoma-blunt trauma
Fig 33-20 p480
Secondary spinal cord injury
A complex cascade of events, free radical-induced lipid
peroxidation reactions, progressive ischemia of gray and white
matter
Diagnostic findings
Clinical features
Neurologic evaluation
Observation: inspection, head or facial trauma-4% to 20% spinal cord
injuries, breathing pattern-phrenic nerve , diaphragm ,C3 and C4 level,
abdominal breathing-lower cervical injury, Horner’s syndrome-unilateral
facial ptosis, miosis, anhydrosis-C7 to T2 cervical sympathetic chain
Speak with the patient-history, severe pain in the sensory dermatome
corresponding to the level of the spinal injury(C2 occipital pain,
C5 trapezius muscle ), burning-hand syndrome C6 to C7 extension
injuries
Palpation: tenderness, deformity, muscle spasms
Motor activity: table 33-3, repeated at frequent intervals-cephalad
progression
Deep tendon reflexes: Table 33-4,
upper motor neuron(spinal cord)-paralyzed muscles, intact deep tendon
reflex, lower- absent DTR(nerve root or cauda equina)-surgically
correctable lesion
Sensory function: Table 33-5, Fig 33-22, cotton wisp-light
touch( posterior column function), pin-pain sensation( anterior
spinothalamic tract function )
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Complete spinal cord lesions:
Total loss of motor power and sensation distal to the site of a spinal
cord injury. Longer than 24 hours-99% will not have functional recovery
Sacral sparing-perianal sensation, rectal sphincter tone, slight flexor
toe movement.---partial lesion
Spinal shock: concussive injury, last less than 24 hours
bulbocavernosus reflex-absent
Incomplete spinal cord lesions: Fig 33-23
Central cord syndrome
Degenerative arthritis of cervical vertebrae, greater neurologic
deficit in the upper extremities, quadriplegic-sacral sparing, 50% a
return of bowel and bladder control, ambulatory, regain some hand
function
Brown-Séquard syndrome:
Hemisection of the spinal cord - penetrating lesion such as
gunshot or knife wound, ipilateral motor paralysis and contralateral
sensory hypesthesia distal to the level of injury---all retain control of
bowel and bladder
Anterior cord syndrome:
Cervical flexion injury—paralysis and hypalgesia (preservation
of position, touch, vibratory sensations ), acute surgical intervention
Three additional spinal cord syndromes:
Dejeune onion skin pattern of analgesia of the face
Horner syndrome
Posteroinferior cerebellar artery syndrome
Radiographic evaluation
Indications: impaired consciousness, complaints of neck or back pain, evidence
of significant head or facial trauma, signs of focal neurologic deficit, unexplained
hypotension, suggestive mechanism of injury associated with other painful injuries,
minor mechanism ofinjury(osteoporosis, arthritis, metastatic disease
Standard trauma series:
AP, lateral, swimmer’s, oblique, open-mouth or closed-mouth odontoid
views, Fig 33-25, Fig 33-26
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Cross-table lateral view: ABCs: Alignment( Fig 33-27 p489 )- 2 mm( Fig
33-28 p489 )-Predental space( 3mm adult, 5mm child) , bony
changes-bony density, cartilage-space assessment-oblique view in
confirming real subluxation , soft tissues- C2 ( 7 mm ), C3( 5mm ), C6
retrotracheal space 22mm( adults ) 14mm ( children)
Odontoid view: Fig 33-26
Other view:
AP view : A bulging of the mediastinal stripe-subtle thoracic vertebral
body fracture, infection or neoplasm( Fig 33-30 p491)
Oblique view: posterior laminar fracture, unilateral facet dislocation,
real subluxation( Fig 33-32 p492)-----laminae( shingles on a roof, intact
ellipse ), Fig 33-31 p491
Lateral flexion and extension: slowly and gently flex and extend their
neck for the x-ray examination but not to the point of causing pain or
neurologic symptoms, 10 to 15 degrees
Further evaluation:
CT scan, Fig 33-33 p493
Major indication for CT scan in cervical spine trauma
1. Inadequate plain film survey
2. Suspicious plain film findings
3. Fracture/displacement demonstrated by standard radiography
4. High clinical suspicion of injury, despite normal plain film survey
Advantages :Fig 33-34 p494
1. Improved fracture-detection rates
2. Spinal canal evaluation, Fig 33-35 p494
3. Paravertebral soft-tissue assessment
4. Reduced manipulation of the patients and exposure to radiation
Disadvatages:
1. Limited demonstration of vertebral body displacement or
subluxation in the sagittal plane
2. Poor visualization of horizontally oriented fractures
--------Spiral CT scan, Fig 33-36 p495( Volume scan )
Three-dimensional format, Fig 33-37 p495
C-spine injuries not apparent on plain film and axial CT
Fig 33-38 p 496
MRI scan: definition of the spinal canal, multiplanar capabilities, lack of
ionizing radiation, surpassing myelography and
postmelography CT scan, Fig 33-39 p497
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Including acute disk herniation, ligamentous injuries,
epidural and subdural hemorrhage, and vertebral artery
occlusion
---potentially correctable surgically, Fig 33-40 p 498
---Cord edema or contusion vs Cord hemorrhage, Fig33-41
p499
Contraindications: the presence of a pacemaker, cerebral aneurysm
clips, metallic ( ferromagnetic ) foreign bodies
Ligamentous injury, Fig 33-42 p500
Subarachnoid changes, Fig 33-43 p501
Management of spinal injuries
Spinal column stabilization
Prehospital care: 10% permanent impaired—immobilize the traumatized
spine or sedate the patient---neck collar,sand bags, tape
Airway management—lesion above the level of C3
---careful orotracheal intubation with in-line spinal immobilization
Spinal shock: loss of neurologic function and accompanying autonomic tone
below the level of a spinal cord lesion
---Flaccid paralysis with loss of all modes of sensory input, deep
tendon reflexes, and urinary bladder tone, along with
bradycardia, hypotension, hypothermia, and intestinal ileus.
---generally lasts less than 24 hours( days, weeks )
Pharmacologics for incomplete cord injury
Glucocorticoids, naloxone, thyrotropin-releasing hormone,
dimethyl sulfoxide,calcium channel blockers, tirilazad meyslate,
GM1 ganglioside, hyperbaric oxygen therapy
--------Methylprednisolone ( within 8 hours of injury )
30 mg/kg IV bolus, 5.4 mg/kg/hr for 23hr
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