Spinal Injuries M. Jamous M. D.

Spinal Injuries
Incidence 30-40/ 1,000,000 person
The mortality rate 40-50%
Most common in the cervical region (55%)
The peak incidence in the young age group (15-25 year-old)
Motor vehicle accidents acounts for 50% followed by falls (25%), athletic accidents (15%), and penetraing injuries (10%)

Acute evaluation and ER management
Strict spine precautions (immobilization)
Emergency resuscitation (ABC..)
Comprehensive approach
Always expect multiple trauma (neuroexam, chest, abdomin,muskuloskeletal…)
Differentiate hggic from neurogenic shock

Neurological and radiological evaluation
In awake patients, both motor and sensory examinations in all extremeties
Unconcious patients: muscle tone, reflexes, rectal sphinctor tone, priapism

Radiological evaluation
Lateral C.S. Xray:
- Accuracy 70-80%
- check alignement, bone and disc space pathology
- Prevertebral soft tissue at C2-C4:
(retropharyngeal < 7mm)
and at C5-C7:
(retrotracheal <20mm)

Radiological evaluation
Dorsal spine Xray:
Not accurate
Lumbar Spine Xray:
70% accuracy

Radiological evaluation
CT scan and
MRI in case of
clinical suspicion
or abnormal Xray

Spinal Injuries
Spinal Column Injuries
Injuries to Neural Structures (spinal cord, nerve roots)
±

Neural injury
secondary injury
• local swelling at the site of injury which pinches off blood (hypoperfusion and ischemia)
• Excessive release of glutamate and excitotoxicity of neurons and oligodendrocytes at the site of injury
• Infiltration by immune cells (microglia,neutrophils)
• Free radical toxicity
• Apoptosis/necrosis

General Management Guidelines
Role of steroids
The North American Spinal Cord Injury Study (NASCIS) showed definite benefit of I.V. high dose methylprednisolone
Given for complete and incomplete injuries
Should be given within 8 hours of the injuries
Dose: 30mg/kg over 1 hr loading dose then 5.4mg/kg/hr for 23 hrs or 48 hrs

Spinal Shock
Transient loss of all neurological function (motor, sensory, and autonomic) below the injury level for 1-2 weeks

Spinal Injuries
Injury level

Spinal Injuries
ASIA IMPAIRMENT SCALE:
A =Complete: No motor or sensory function is preserved
B =Incomplete: Sensory but not motor function is preserved
C =Incomplete: Non-useful motor function is pre-served below the neurological level
D =Incomplete: Useful motor function is pre-served below the neurological level
E =Normal: Motor and sensory func-tionare normal.

Incomplete Spinal Injuries
CLINICAL SYNDROMES:
Central Cord: greater motor deficit in the upper extremities
Brown-Sequard: dissociated sensory loss, ipsilateral paralysis
Anterior Cord: paraplegia, quadriplegia

Incomplete Spinal Injuries
CLINICAL SYNDROMES:
Conus Medullaris: saddle anesthesia, incontinence (painless, symmetrical)
Cauda Equina: saddle anesthesia, incontinence (painful, asymmetrical)

Spinal Column Injury
Atlanto-occipital dislocation
Atlanto-occipital dislocation (AOD) is a devastating condition that frequently results in prehospital cardiorespiratory arrest
accounts for 1% of spinal trauma.
AOD occurs 3 times more commonly in children than adults,
hyperextension.
Unstable
Power’s ratio=BC/OA<1

Spinal Column Injury
Atlanto-Axial dislocation
Lower mortality than Atlanto-occipital dislocation
1/3 of patients have deficit
Transverse ligament injury
AAD occurs more commonly in children than adults
Non-traumatic in downs syndrome and Rheumatoid arthritis
Unstable
ADI> 5mm

Spinal Column Injury
Atlas (C1) fractures
Described as Jefferson #
Axial load
Usually no neurological deficit
1/3 have C2 #
Usually stable

Spinal Column Injury
Axis (C2) #
Includes Hangman’s # and Odontoid process #
HANGMAN’S #
Bilateral # of the isthmus of the pedicles of C2 with anterior sublaxation of C2-C3
Hyperextention and axial loading
Usually stable

Spinal Column Injury
Axis (C2) #
Includes Hangman’s # and Odontoid process #
Odontoid #
Flexion injury
15% of all cervical injuries
II unstable,I & III stable
I
II
III

Spinal Column Injury
Subaxial (C3-C7) #
Whiplash injury:
Traumatic injury to the soft tissue in the cervical region
Hyperflexion, hyperextention
No fractures or dislocations
Most common automobile injury
Recover 3-6 months

Spinal Column Injury
Subaxial (C3-C7) #
Vertical compression injury:
Loss of normal cervical lordosis
Burst #
Compression of spinal cord
Unstable
Requires decompression and fusion

Spinal Column Injury
Subaxial (C3-C7) #
Compression flexion injury (teardrop #)
Classical diving injury
Posterior elements involved in >50%
Displacement of inferior margin of the body
Unstable
Requires stabilization

Spinal Column Injury
Subaxial (C3-C7) #
flexion distraction injury (locked facet)
>50% displacement
Unstable
Requires reduction and stabilization

Spinal Column Injury
Subaxial (C3-C7) #
extention injury (# posterior elements)
# lamina, pedicles or spinous process
With or without ligamentous injury
Usually stable

Spinal Column Injury
Thoracic and lumbar #
Stability (three column model of Denis)
Injury affecting two or more column is unstable

Spinal Column Injury
Thoracic and lumbar #
Compression #
Burst #
Chance # (seat belt)
Flexion distraction
Fracture dislocation

General Management Guidelines
Strict spine precautions (immobilization)
Emergency resuscitation (ABC..)
Comprehensive approach
Neurological and Radiological assesment.
Always expect multiple trauma (neuroexam, chest, abdomin,muskuloskeletal…)
Differentiate hggic from neurogenic shock