Spinal Injury

&
Spinal Cord
Injury
 OUTLINE

• Goal of spine trauma care

• Pre-hospital management
• Clinical and neurologic assessment
• Acute spinal cord injury
• Term, type and clinical characteristic
• Common cervical spine fracture and dislocation
 GOAL

• Protect further injury during evaluation and

management

• Identify spine injury or document absence of spine

injury

• Optimize conditions for maximal neurologic

recovery
 GOAL

• Maintain or restore spinal alignment

• Minimize loss of spinal mobility

• Obtain healed & stable spine

• Facilitate rehabilitation
 Suspected Spinal Injury

• High speed crash

• Unconscious
• Multiple injuries
• Neurological deficit
• Spinal pain/tenderness
 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)

• Neutral position
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  most important
• Early intubation is critical to limit secondary injury
from hypoxia (with safe intubation/minimize neck
manipulation)
 Physical examination

• Information
• Mechanism
• energy (High speed crash), energy (fall
<2 m)
• Direction of Impact
• Associated Injuries
 Is the patient awake or
“unexaminable”?
• What’s the difference ?
• Awake OW!
• ask/answer question
• pain/tenderness
• motor/sensory exam

• Not awake
• you can ask (but they won’t answer)
• can’t assess tenderness
• no motor/sensory exam

------
“Tidak dapat diperiksa”

“TIDAK diperiksa”
 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 injury)

 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
• 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 Hypovolemic
Etiology Loss of sympathetic Loss of blood volume
outflow
Blood Hypotension Hypotension
pressure
Heart rate Bradycardia Tachycardia

Skin Warm Cold

temperature
Urine Normal Low
output 22
 Definitions of terms
• Neurologic level
• Most caudal segment with normal sensory and motor function both
sides
• Skeletal level
• Radiographic level of greatest vertebral damage
• Complete injury
• Absence of sensory and motor function in the lowest sacral segment
• Incomplete injury
• Partial preservation of sensory and/or motor function below the
neurologic level
 Neurologic assessment
• Spinal shock
• Bulbocavernosus reflex

• Complete VS incomplete cord injury

• spinal shock
• Sacral sparing
• 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)
• Key sensory points : 28 dermatomes
 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
 Radiographic imaging
• Who needs an x- ray of the spine ?

 NEXUS -The National Emergency X- Radiograph Utilization

Study
• Prospective study to validate a rule for the decision to obtain cervical
spine x- ray in trauma patients
• Hoffman, N Engl J Med 2000; 343:94-99
 Canadian C-Spine rules
• Prospective study whereby patients were evaluated for 20 standardized
clinical findings as a basis for formulating a decision as to the need for
subsequent cervical spine radiography
• Stiell I. JAMA. 2001; 286:1841-1846
 NEXUS

• NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
 NEXUS
• Patient who fulfilled all 5 of the criteria were considered low
risk for C-spine injury
 No need C-spine X-ray

• For patients who had any of the 5 criteria

 radiographic imaging was indicated
( AP, lateral and open mouth views)
 The Canadian C-spine Rule for alert and stable trauma patients where cervical spine injury is a
concern.

• Any high-risk factor that mandates radiography?

• Age>65yrs or
• Dangerous mechanism or
• Paresthesia in extremities

NO
Any low-risk factor that allows safe
YES
assessment of range of motion?
• Simple rear-end MVC, or NO
• Sitting position in ER, or Radiography
• Ambulatory at any time, or
• Delayed onset of neck pain, or
• Absence of midline C-spine tenderness

YES
Able to actively rotate neck? UNABLE
• 45 degrees left and right
ABLE
No Radiography
 National Emergency X
Radiography Utilization Study
(NEXUS)

&
The Canadian C-spine rule

Both have:
• Excellent negative predictive value for excluding patients
identified as low risk
 Clearance of Cervical Spine Injury in
Conscious, Symptomatic Patients

1. Radiological evaluation of the cervical spine is indicated for all

patients who do not meet the criteria for clinical clearance as
described above

2. Imaging studies should be technically adequate and interpreted by

experienced clinicians
 Cervical Spine Imaging Options
• Plain films
• AP, lateral and open mouth view
• Optional: Oblique and Swimmer’s

• CT
• Better for occult fractures

• MRI
• Very good for spinal cord, soft tissue and ligamentous injuries

• Flexion-Extension Plain Films

• to determine stability
 Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS

• Adequacy, Alignment
• Bone abnormality, Base of skull
• Cartilage
• Disc space
• Soft tissue
Basic Anatomy
Cervical
 Adequacy

• Must visualize entire C-spine

• A film that does not show the upper
border of T1 is inadequate
• Caudal traction on the arms may help
• If can not, get swimmer’s view or CT
Swimmer’s view
Alignment
• The anterior vertebral line,
posterior vertebral line, and
spinolaminar line should
have a smooth curve with
no steps or discontinuities

• Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be
due to rotation

• A step-off of >3.5mm is
significant anywhere
 Lateral Cervical Spine X-Ray

• Anterior subluxation of one vertebra on

another indicates facet dislocation
• < 50% of the width of a vertebral body 
unilateral facet dislocation
• > 50%  bilateral facet dislocation
Bones
Disc
• 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)
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 fracture lines
 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%
• Ideally all patients with MRI
abnormal neurological
examination should be
evaluated with MRI scan
• Primary Goal Management of SCI
• 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 :
• Acute respiratory failure
• GCS <9
• Increased RR with hypoxia
• PCO2 > 50
• VC < 10 mL/kg
• IV Access & fluids titrated to BP ~ 90-100 mmHg
 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
Jefferson Fracture

• Burst fracture of C1 ring

• Unstable fracture

• Increased lateral ADI on lateral

film if ruptured transverse
ligament and displacement of C1
lateral masses on open mouth
view

• Need CT scan
Burst Fracture

• Fracture of C3-C7 from axial

loading

• Spinal cord injury is common

from posterior displacement
of fragments into the spinal
canal

• Unstable
Clay Shoveler’s Fracture

• Flexion fracture of spinous

process

• C7>C6>T1

• Stable fracture
Flexion Teardrop Fracture
• Flexion injury causing a fracture of
the anteroinferior portion of the
vertebral body

• Unstable because usually

associated with posterior
ligamentous injury
Bilateral Facet Dislocation

• Flexion injury
• Subluxation of dislocated
vertebra of greater than ½ the
AP diameter of the vertebral
body below it
• High incidence of spinal cord
injury
• Extremely unstable
Hangman’s Fracture

• Extension injury

• Bilateral fractures of C2
pedicles
(white arrow)

• Anterior dislocation of
C2 vertebral body (red
arrow)

• Unstable
 Odontoid Fractures
• Complex mechanism of injury
• Generally unstable
• Type 1 fracture through the tip
• Rare
• Type 2 fracture through the base
• Most common
• Type 3 fracture through the base and body of axis
• Best prognosis
Odontoid Fracture Type II
Odontoid Fracture Type III
 Thank you
for your attention