Spine (Vertebrae) Fracture
And Spinal Cord Injury
Dr. Hermansyah, SpOT
Bag. Bedah/ SMF Orthopedi
FK-Unand/ RSUP Dr. M. Djamil Padang
RSUD Lubuk Basung
Normal Spinal Anatomy
Spinal ligament
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Intrasegmental
Ligamentum flavum
Intertransverse ligament
Interspinous ligament
Intersegmental
ALL
PLL
Supraspinous ligament
Epidemiology
Incidence: 10,000 new cases/year
Prevalence: 191,000 cases and rising
Prime occurrence: males, peak of their
productive lives
Cost: $ 5.6 billion/year in the US
Cost per person: directly related to the
level
of SCI and patient’s age
Common Mechanisms
Compression
 Flexion
Extension
Rotation
Lateral bending
Distraction
Penetration
Whiplash injury
Suspect spinal injury with...
 Sudden decelerations (MVCs, falls)
 Compression injuries (diving, falls onto feet/buttocks)
 Significant blunt trauma (football, hockey
snowboarding, jet skis)
 Very violent mechanisms (explosions, cave-ins,
lightning strike)
 Unconscious patient
 Neurological deficit
 Spinal tenderness
Neurological
assessment: Sensory
Goal of spine trauma care
Protect further injury during evaluation
and management
Identify spine injury or document
absence of spine injury
Optimize conditions for maximal
neurologic recovery
Goal of spine trauma care
Maintain or restore spinal alignment
Minimize loss of spinal mobility
Obtain healed & stable spine
Facilitate rehabilitation
Pre-hospital management
 Protect spine at all times during the
management of patients with multiple
injuries
 Up to 15% of spinal injuries have a
second (possibly non adjacent) fracture
elsewhere in the spine
 Ideally, whole spine should be
immobilized in neutral position on a firm
surface
PROTECTION  PRIORITY
Detection  Secondary
“Log-rolling”
Pre-hospital management
Cervical spine immobilization
Transportation of spinal cord-injured
patients
Cervical spine immobilization
“Safe assumptions”
Head injury and unconscious
Multiple trauma
Fall
Severely injured worker
Unstable spinal column
 Hard backboard, rigid cervical collar and lateral
support (sand bag)
Philadelphia hard collar
Transportation of spinal cord-injured
patients
Emergency Medical Systems (EMS)
Paramedical staff
Primary trauma center
Spinal injury center
Clinical assessment
Advance Trauma Life Support (ATLS)
guidelines
Primary and secondary surveys
Adequate airway and ventilation are the
most important factors
Supplemental oxygenation
Early intubation is critical to limit
secondary injury from hypoxia
Physical examination
Inspection and palpation
Occiput to Coccyx
Soft tissue swelling and bruising
Point of spinal tenderness
Gap or Step-off
Spasm of associated muscles
Neurological assessment
Motor, sensation and reflexes
PR
Do not forget the cranial nerve (C0-C1
Neurogenic Shock
Temporary loss of autonomic function of
the cord at the level of injury
 results from cervical or high thoracic injury
Presentation
Flaccid paralysis distal to injury site
Loss of autonomic function
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hypotension
vasodilatation
loss of bladder and bowel control
loss of thermoregulation
warm, pink, dry below injury site
bradycardia
Comparison of neurogenic and hypovolemic shock
Neurogenic
Etiology
Hypovolemic
Loss of sympathetic Loss of blood volume
outflow
Blood
pressure
Hypotension
Hypotension
Heart rate
Bradycardia
Tachycardia
Skin
temperature
Warm
Cold
Urine
output
Normal
Low
20
Neurologic assessment
Spinal shock
Bulbocavernosus reflex
Complete VS incomplete cord injury
ต้องพ้นภาวะ spinal shock ไปก่อน
Sacral sparing
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Voluntary anal sphincter control
Toe flexor
Perianal sensation
Anal wink reflex
Neurologic assessment
American Spinal Injury Association
grade
Grade A – E
American Spinal Injury Association
score
Motor score (total = 100 points)
• Key muscles : 10 muscles
Sensory score (total = 112 points)
Incomplete cord injury
Anterior cord syndrome
Brown-Sequard syndrome
Central cord syndrome
Anterior cord syndrome
 Loss of motor, pain
and temperature
 Preserved
propioception and
deep touch
Brown-Sequard syndrome
 Loss of ipsilateral
motor and
propioception
 Loss of contralateral
pain and
temperature
Central cord syndrome
 Weakness :
upper > lower
 Variable sensory
loss
 Sacral sparing
IMAGING
Numerous large prospective studies have
described the large cost and low yield of
the indiscriminate use of c-spine radiology
in trauma patients.
WHO NEEDS AN X-RAY???
NEXUS
Criteria were as follows…..
1. Absence of tenderness in the posterior
midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS15)
4. No evidence of intoxication
5. No distracting pain elsewhere
NEXUS
1. Any patient who fulfilled all 5 of the
aforementioned criteria were
considered low risk for C-spine injury
and as such did not receive C-spine
radiography
2. For patients who had any of the 5
criteria,radiographic imaging was
indicated in the form of AP, lateral, and
odontoid C-spine views
Canadian C-Spine Rules
Plain Film Radiology
 The standard 3 view plain film series is the lateral,
antero-posterior, and open-mouth view
 The lateral cervical spine film must include the base of
the occiput and the top of the first thoracic vertebra
 The lateral view alone is inadequate and will miss up
to 15% of cervical spine injuries.
X-ray Guidelines (cervical)
Adequacy, Alignment
Bone abnormality, Base of skull
Cartilage, Contours
Disc space
Soft tissue
Interpreting Lateral Plain
Film
 Adequacy
Should see C7-T1
junction
If not get
swimmer’s view or
CT
Swimmer’s View
Interpreting lateral Plain Film
 Alignment
Anterior vertebral line
• Formed by anterior borders of vertebral bodies
Posterior vertebral line
• Formed by posterior borders of vertebral bodies
Spino-laminar Line
• Formed by the junction of the spinous processes and the
laminae
Posterior Spinous Line
• Formed by posterior aspect of the spinous processes
Alignment
Bones
Cartilage
 Predental Space
should be no more
than 3 mm in
adults and 5 mm in
children
 Increased distance
may indicate
fracture of odontoid
or transverse
ligament injury
Cartilage Cont.
 Disc Spaces
Should be uniform
 Assess spaces
between the
spinous processes
Soft tissue
 Nasopharyngeal
space (C1) - 10 mm
(adult)
 Retropharyngeal
space (C2-C4) - 5-7
mm
 Retrotracheal space
(C5-C7) - 14 mm
(children), 22 mm
(adults)
 Extremely variable
and nonspecific
Measurements anterior to the mid-cervical spine up to 7 mm are
common. > 7 mm,-a fracture is likely and the neck should be
immobilized.
AP C-spine Films
Spinous processes
should line up
Disc space should
be uniform
Vertebral body
height should be
uniform. Check for
oblique fractures.
Open mouth view
Adequacy: all of
the dens and
lateral borders of
C1 & C2
Alignment:
lateral masses of
C1 and C2
Bone: Inspect
dens for lucent
CT Scan
Thin cut CT scan
should be used to
evaluate abnormal,
suspicious or poorly
visualized areas on
plain film
The combination of
plain film and directed
CT scan provides a
false negative rate of
less than 0.1%
MRI
Ideally all patients
with abnormal
neurological
examination should
be evaluated with
MRI scan
Management of SCI
Primary Goal
Prevent secondary injury
Immobilization of the spine begins in the
initial assessment
Treat the spine as a long bone
• Secure joint above and below
Caution with “partial” spine splinting
Management of SCI
Spinal motion restriction: immobilization
devices
ABCs
Increase FiO2
Assist ventilations as needed with c-spine
control
 Indications for intubation :
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Acute respiratory failure
GCS <9
Increased RR with hypoxia
PCO2 > 50
Management of SCI
Look for other injuries: “Life over Limb”
Transport to appropriate SCI center once
stabilized
Consider high dose methylprednisolone
Controversial as recent evidence questions
benefit
Must be started < 8 hours of injury
Do not use for penetrating trauma
30 mg/kg bolus over 15 minute
After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatment
Spinal alignment
deformity/subluxation/dislocation
reduction
Spinal column stability
unstable  stabilization
Neurological status
neurological deficit  decompression
Complete - Absence of sensory and
motor functions in the lowest sacral
segments
Incomplete - Preservation of sensory or
motor function below the level of injury,
including the lowest sacral segments
Frankel scale
A complete paralysis
B sensory function only below the injury
level
C incomplete motor function below
injury level
D fair to good motor function below
injury level E normal function
Treatment
Suportif
Non Operative
Surgery
Steroid Protocol: for Spinal
Cord Injury
 Methylprednisolone given as bolus of 30
mg / kg body wt - followed by infusion at
5.4 mg / kg / hour for 23 hours;
 Excluded pts: - patients who are more
than 8 hours from injury (these patients
may actually do worse w/ steroids);
 Note: up to 40% of spine injured patients
who receive steroids can be expected to
develop some Gastrointenstinal bleeding
Non – Operative Treatment
Options
No treatment
advice / restrict activity
Spinal ‘immobilisation’
Bed rest
Lumbar pillow / Log
rolling
Traction
Casting / Bracing
Combination treatment
Guilford brace
Stable A3 Fracture
Bed Rest until Normal Trunk Control
Standing X Rays
? Use extension Brace or Cast
Indications for surgery
1.The spinal cord appears to be compressed
2.An progressive neurological deterioration.
3.Dislocation with facet joint locking
4.Unstable fracture of spine
Occipitoatlantoaxi
al fusion with the
Luque rectangle
C Type Fracture L2
USS2 Fracture Set –
Fixation of A3 Fracture
Complications
A Infection of urinary and genital tract
B. Pressure Sores : Prevention is the
most important treatment.
C. Respiratory Complications :
respiratory infection
D. Disorder of thermoregulation
PELVIC RING FRACTURE
PELVIC FRACTURES: CLASSIFICATION &
MANAGEMENT
Hermansyah
Bag Bedah/ SMF Orthopedi
FK-Unand/ RSUP Dr. M.Djamil Padang
 Pelvic fractures are caused by high energy blunt
trauma
 Significant mortality and morbidity
 Mortality 30% in unstable fractures
10 to 12% due to haemorrhage
ANATOMY
 Sacrum and 2
innominate bones
 Innominate bones
articulate anteriorly
at symphysis pubis
 Sacrum articulates
with the ilium
posteriorly through
sacroiliac joints
ANATOMY
Pelvic ring stability is
provided by:
 Iliolumbar ligs.
 Dorsal sacroiliac
ligaments
 Sacrotuberous ligs
 Ventral sacroiliac ligs.
 Sacrospinous ligs
 Posterosuperior
interosseous ligs.
ANATOMY
 Highly vascular
 Iliac vessels run
along the inner
wall of the pelvis
Trauma Mechanism
YOUNG and BURGESS
CLASSIFICATION
 Tile’s classification system uses radiographic
images to ascertain the degree of stability of the
pelvis , and hence determine which pelvic injuries
require stabilization and which can be managed
nonoperatively.
 Hence the classification by Tile is more relevant for
formulating treatment, but does not give significant
information regarding the degree of damage
CLASSIFICATION
Type A: Stable (Posterior Arch Intact)
A1:Avulsion injury
A2:Iliac wing or anterior arch fracture caused
by a direct blow
A3: Transverse sacrococcygeal fracture
Type B: Partially Stable (Incomplete
Disruption of Posterior Arch)
B1:Open book injury (external rotation)
B2:Lateral compression injury (internal
rotation)
B2-1:Ipsilateral anterior and posterior injuries
B2-2:Contralateral (bucket-handle) injuries
B3:Bilateral
Type C: Unstable (Complete Disruption of
Posterior Arch)
C1:Unilateral
C1-1:Iliac fracture
C1-2:Sacroiliac fracture-dislocation
C1-3:Sacral fracture
C2:Bilateral, with one side type B, one side
type C
C3:Bilateral
TREATMENT
INITIAL MANAGEMENT:
 ATLS protocol: Primary survey
 IV fluids and blood transfusion with wide bore canula
 A/P Xray of pelvis, L/S spine, Chest, Cervical spine (lat
view)
 If blood is seen on external urethral meatus, suprapubic
cystostomy is preferable to catheterization.
 Multidisciplinary approach
Prioritising
ABDOMEN
HEAD
PELVIS
CHEST
How to stabilise the Pelvis
Rotational instability – Binding – III – 3
Vertical instability – skeletal traction – III
–3
Non invasive external stabilisation
devices or a bed sheet but allow access
to laparotomy and femoral access for
angiography – IV
ITIM
If Non invasive fails invasive anterior
external fixation - IV
Circumferential Sheeting
2
 Supine
1
 2 “Wrappers”
 Placement
 Apply
 “Clamper”
4
3
 30 Seconds
Routt et al, JOT, 2002
SAM SLING
TREATMENT
HAEMODYNAMICALLY STABLE:
 Complete secondary survey
 Inlet and outlet views, Pelvic CT scan
 Pelvic binder for unstable fractures
 Definitive fixation
TREATMENT
HAEMODYNAMICALLY UNSTABLE
PELVIC BINDER
UNSTABLE
UNRESPONSIVE
TO IV FLUIDS
RESPONDS TO
IV FLUIDS
STABLE
SECONDARY
SURVEY
TREATMENT
RESPONSE TO IV FLUIDS
RESPONDS, BUT REQUIRES
CONTINUOS INFUSION
UNRESPONSIVE
SECONDARY SURVEY, USG,
PERITONEAL ASPIRATION
URGENT
LAPAROTOMY
TREATMENT
SECONDARY SURVEY, PERTONEAL
Asp, USG, CT
NO INTRAPERITONEAL
BLEEDING
INTRAPERITONEAL
BLEEDING
ANGIOGRAPHY &
EMBOLISATION
LAPAROTOMY
LAPAROTOMY
EX-FIX
HGE CONTROL
PELVIC PACKING
REMAINS UNSTABLE
BP STABILIZES
ANGIOGRAPHY
FOLLOWED BY
EMBOLIZATION
DEFINITIVE FIXATION
PELVIC EXTERNAL FIXATOR
 Damage control
surgery, Minimally
invasive
 Stabilizes rotationally
unstable pelvis, in
patients with shock
 Before laparotomy
Immediate External Fixation
Pelvic “clamps”
Percutaneous fixation
 Exposure not a
problem
 Low complication rate
 Bio mechanically
ideal
 Detailed anatomical
knowledge required
 Technically
demanding
DEFINITIVE FRACTURE FIXATION
 INDICATIONS:
1. Symphyseal diastasis > 2cm
2. Contralateral bucket handle injury causing >1.5cm
limb length discrepancy
3. Rotationally and vertically unstable fractures (Tiles
Type C)
 TIMING
When patient is stabilized, and fit enough to
undergo the definitive procedure
DEFINITIVE FRACTURE
FIXATION
 Lag screw,
Neutralization plates for
Iliac wing fractures
 Plate fixation for
Symphyseal diastasis
DEFINITIVE FRACTURE
FIXATION
 Plate fixation,
sacroiliac screw
fixation for Sacral
fractures
 Cancellous screw
or Sacroiliac plate
fixation for
Sacroiliac disruption
ANGIOGRAPHY
SUMMARY
 Stabilization of a haemodynamically unstable patient
is of paramount importance.
 Unstable pelvic fractures should be stabilized
externally as soon as possible.
 For unresponsive patients, urgent laparotomy with
angiography on stand by.
 Not all pelvic fractures requires fixation.