spine trauma

Spine Trauma

Teuku Nanda Putra

Anatomy

Cervical Small vertebral bodies (lesser

weight bearing) Extensive joint surfaces

allows greater ROM (rot, flex, ext)

Thoracic Rib bearing vertebrae Designed to remain stiff

(minimal flex, ext)

Lumbar Weight-bearing vertebrae,

houses cauda equine. (min rot)

Sacral Transmits weight of body to

the pelvis. (no motion)

Anatomy

Anatomy Spinal nerve roots pass out intervertebral foramen

C1-7 exit above C8-L5 exit below

Spinal nerve: ventral (motor), dorsal (sensor)

Sensoric cells in dorsal Motoric cells in Ventral horn

Cauda equina formed by L & S nerve in the spinal canal

before exiting

Mechanism of injuryDirect injury

Penetrating injuries to the spine, particularly from firearms and knives

Indirect injuryMost common cause of significant spinal damageFall from a height spinal column collapses in vertical axisForces: axial compression, flexion, lateral compression, flexion-rotation, shear, flexion-distraction and extension

Eisenstein S, Marsy WE. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010

• Motorcycle crashes • Falls• Hangings• Blunt trauma• Penetrating trauma to the head, neck• Gunshot wounds• Any unresponsive trauma patient

Suspicious: A Spine Injury?

Stable vs Unstable

Treat as unstable until proven otherwise

Stable injuriesVertebral components will not be displaced by normal movements. Little risk of neural damage

Unstable injuries There is a significant risk of displacement and consequent damage – or further damage – to the neural tissues

Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010

Clinical Evaluation

Injuries of the vertebral column tend to cluster at the junctional areas:

Craniocervical junction (occiput to C2)Cervicothoracic junction (C7-T1)Thoracolumbar junction (T11-L2).


DiagnosisKEY POINTS:

Every patient with a blunt injury above the clavicle, a head injury or loss of consciousness should be considered to have a cervical spine injury until proven otherwise

Every patient who is involved in a fall from a height or a high-speed deceleration accident should similarly be considered to have a thoracolumbar injury

Consider the presence of a vertebral column injury in all patients with multiple injuries

Lesser injuries also should arouse suspicion if they are followed by pain in the neck or back or neurological symptoms in the limbs


Signs & Symptoms Suggestive of Spine Trauma

• Respiratory distress• Tenderness at the site of injury on spinal column• Pain along the spinal column with movement• Deformity of the spine (rare)• Numbness, weakness or tingling in the arms or legs• Loss of sensation or paralysis in the upper or lower extremity• Incontinence or loss of bowel or bladder control


A general physical examination is done with the patient supineABC!Spinal shock & neurogenic shock Neurogenic shock

Peripheral vessels dilate hypotension, but the heart doesn’t respond by increasing its rateParalysis, warm and well-perfused peripheral areas, bradycardia and hypotension with a low diastolic blood pressure.

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


Diagnosis : physical exam

HeadHead: laceration, contusion, and palpate for facial fractureEar canal: inspect to rule out leakage of spinal fluid or bloodThe spinous processes should be palpated from the upper cervical to the lumbosacral region. A painful spinous process may indicate a spinal injury

NeckAny complaint of pain or tenderness indicative of a spinal injury collar immobilizationNeck motion only after the patient reports no pain or tenderness during examination of the neckAn assistant should hold the neck steady in a neutral position



Sensory examination:Sensation to light touchPinprick sensibility

Motor strengthPhysiological and pathological reflexesMotor and sensory evaluation of the rectum and perirectal area

Incontinence of the bowel or bladder suggest a significant spinal injury


Sacral Sparing

Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing.

Complete - Absence of sensory and motor functions in the lowest sacral segmentsIncomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7 th edition. 2010

Evaluating Sacral Sparing

Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing.

Sacral sparing may include the triad of perianal sensation, rectal tone, and great toe flexion

Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7th edition. 2010

ImagingX-ray examination (in secondary survey) of the spine is mandatory for:

All accident victims complaining of pain or stiffness in the neck or back or peripheral paraesthesiaeAll patients with head injuries or severe facial injuriesPatients with rib fractures or severe seat-belt bruisingSevere pelvic or abdominal injuriesAccident victims who are unconsciousElderly people Patients with known vertebral pathology (e.g. ankylosing spondylitis)

ImagingMinimum of movement and manipulationApart from AP and lateral views:

Open-mouth views: C1 and C2CT structural damage of individual vertebrae and displacement of bone fragments into the vertebral canalMRI IV discs, ligamentum flavum and neural structures

indicated for all patients with neurological signs and those who are considered for surgery

Compression FractureSubtypes of compression fractures:

Type A: Fracture of both endplates Type B: Fracture of superior endplateType C: Fracture of inferior endplate Type D: Both endplates intact

Burst Fracture• Type AFracture of both end-

plates

• Type BFracture of the superior

end-plate

• Type CFracture of the inferior

end-plate

• Type DBurst rotation

• Type EBurst lateral flexion

Seatbelt-type Injury

Fracture-Dislocation

Shear type

Flexion-Rotation type

Flexion-Distraction type

Classification of Neurological Function

Sensory MotorA Absent Absent

B Present Absent

C Present Active but not useful (grade 2-3)

D Present Active and useful (grade 4)

E Normal Normal

Frankel Classification Grading System

ASIA Impairment ScaleASIA Grad

eClinical state (below level of injury)

A Complete Complete: no sensory or motor function preserved in sacral segments S4 – S5

B Sensory incomplete

Incomplete: sensory, but no motor function in sacral segments

C Motor incomplete

Incomplete: motor function preserved below level and power graded < 3

D Motor incomplete

Incomplete: motor function preserved below level and power graded 3 or more

E Normal Normal: sensory and motor function normal

PRINCIPLES OF MANAGEMENT

Principles of Diagnosis and Initial Management

Early managementABCD then assessment of spinal injuryThe spine immobilized until the patient has been resuscitated and other life-threatening injuries have been identified and treatedImmobilization is abandoned only when spinal injury has been excluded by clinical and radiological assessment

Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010

Initial Temporary Immobilization

Quadruple immobilizationBackboard, sandbags, forehead tape, semirigid collar

Scoop stretcher, spine board, log-roll Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th edition. 2010

CorticosteroidNational Acute Spinal Cord Injury Study I, II, and III Protocols

Methylprednisolone bolus 30mg/kg infusion 5.4mg/kg/h

Infusion for 24h if bolus given within 3 hours of injury

Infusion for 48h if bolus given within 3-8 hours after injury

No benefit if >8h

> 8 hr the consensus is clear that there is no indication for steroid use

Oleson CV, et al. Principles of spine trauma care. Rockwood and Green’s Fractures in Adults, 7 th edition. 2010

Principles of definitive treatment

The objectives of treatment:To preserve neurological function;To minimize a perceived threat of neurological compression;To stabilize the spine;To rehabilitate the patient.

The indications for urgent surgical stabilization are:An unstable fracture with progressive neurological deficit and/or MRI signs of likely further neurological deteriorationControversially an unstable fracture in a patient with multiple injuries Eisenstein S, et al. Injuries of the spine. Apley’s System of Orthopaedics and Fractures. 9th

edition. 2010

Non-surgicalClosed treatment remains the standard of care for most spinal injuriesBedrest, halo apparatus, external orthosis, cast

Surgical

The only consistent indication for surgical treatment skeletal disruption in the presence of a progressive neurological deficit.

Unstable injuries

Thank you

spine trauma

Healthcare