TRAUMA MEDULA SPINALIS

Dr. Rendra leonas SpOT

ORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY
MOH. HOESIN PALEMBANG
 Introduction
Most common
age and high speed level
traffic accident >>
80% spinal inj not assoc SI
more important preliminary care
 At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.
 Anatomy and Physiology
33 bones comprise the spine
• Function
– Skeletal support structure
– Major portion of axial skeleton
– Protective container for
spinal cord
• Vertebral Body
– Major weight-bearing
component
– Anterior to other
vertebrae components
 Anatomy and Physiology
SPINAL NERVES
• 31 pairs of spinal nerves :
• 8 cervical
• 12 thoracic
• 5 lumbar
• 5 saccral
• 1 coccygeal
• Each has both motor and sensory fibers
– Motor fibers = anterior or ventral root
– Sensory fibers = posterior or dorsal root
 Anatomy and Physiology
Components of
Vertebrae
– Spinal Canal
• Opening in the
vertebrae that the spinal
cord passes through
– Pedicles
• Thick, bony structures
that connect the
vertebral body to the
spinous and transverse
processes
 Anatomy
• Spinal cord ends below lower border of L1
• Cauda equina is below L1
• Mid dorsal spinal cord & neural canal space are of
same diameter hence prone for complete lesion

• Mechanical injury - early ischaemia, cord edema -

cord necrosis
• Neurological recovery unpredictable in cauda equina
ie. peripheral nerves
 OVERVIEW

• LOOK
– inspection
• FEEL
– palpation
• MOVE
– active & passive
movements
 EXAMINATION :STANDING

Feel :
• Tenderness: may be bony, intervertebral or
paravertebral
• Bony prominence or steps
spinous processes
– using C7 &/or L4-5
– as landmarks
facet joints
– approx. 2cm lateral to spinous processes
 EXAMINATION : STANDING

Feel :
assess alignment, mobility & tenderness
of:
– transverse processes of vertebrae
 lateral to spinous processes
Signs of nerve root compression

Standard full neurological examination of both

lower limbs :
• tone, power (MRC grading)
• sensation (light touch, pinprick & proprioceptive
if indicated)
• reflexes (physiologic and patologic)
• an anatomical distribution [dermatome(s) or
myotome(s)]
 Neurological Examination
• Objectives :
– Determine if defect is present
– Localize the level of the deficit
• Include :
– Sensory
– Motor
– Reflex
 Neurological Examination
Sensory examination
• Explain, eyes closed
• Examine : touch, 2 point discrimination,
proprioceptive.
• Sensory dermatomes, compare each opposite
Sensory Dermatome
 Muscle Power Grading
• 0 - complete paralysis
• 1 - flicker of contraction possible
• 2 - movement is possible when gravity is excluded
• 3 - movement is possible against gravity
• 4 - movement is possible against gravity + some
resistance
• 5 - normal power
 Neurological Examination
Motor examination
• Muscle grading
• Compare each side
Cervical :
Scapular C4
Deltoid & Biceps C5
Wrist extension & supination C6
Wrist flexion & Pronation C7
 Neurological Examination
Motor examination
• Lumbo-sacral
Hip flexor L 1,2,3
Hip extensor S1

Knee flexor L 4,5, S1,2

Knee extensor L 2,3,4
Ankle flexor S1
Ankle extensor L5
 Denis’ 3 Column Theory

Denis, F.: The Three-Column Spine and its Significance in the

Classification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)
 Cervical spine anatomy
• Anterior column - Anterior longitudinal ligament+
Anterior annular ligament and anterior half of VB.

• Middle column – Posterior long. Lig. + Posterior

annular ligament +Posterior half of VB.

• Posterior Column – Lig flavum + superior &

Interspinous lig + intertransverse capsular lig + neural
arch + pedicle & spinous process.
 Basic Types of Spine Fractures

1. Compression fracture
2. Burst fracture Denis’
Classification
 Basic Types of Spine Fractures

3. Seat-belt injury (Flexion-distraction injury)

Bony Chance fracture Soft tissue Chance injury

 Basic Types of Spine Fractures

4. Fracture-dislocation

Anterior posterior shear

Flexion-rotation Flexion-distraction
 Classification spine fracture
• Stable injury : compression fracture
burst fracture

• Unstable injury : dislocation

fracture dislocation
chance fracture
 Classification spine fracture
• Location :
1. Jefferson fracture
2. Dens fracture
3. Hangman’s fracture
4. Clay shoveler’s fracture
5. SCIWORA
 Compression fracture
• Failure of the anterior column
• Mechanism anterior or lateral flexion
• Normally Stable or unstable fracture
• Rarely involved neurologic comprimise
Criteria unstable

• Loss of 50% of vert body height

• Angulation of thoracolumbar junct > 20 deg
• Mutiple adjacent column of spine
• Failure of 2/3 of column of spine
 Chance fracture
• Anterior column falls in tension (along w/ the
middle and posterior columns)
• Three columns rupture in distraction (tension)
• Seldom assc w/ neurologic comprimise unless
• Unstable
 Burst fracture
• Compressive failure of vert body both
anteriorly & posteriorly , w/ failure of both
anterior & middle columns
• Axial loading applied to intravertebral disc
results in increased nuclear pressure and hoop
stresses in the annulus
Burst frx location
• Cervical burst fix
• Lumbar burst fix
• Thoracic burst fix
• Thoracolumbar burst fix
Classification :
• Stable frx
- neurologically intact
- poterior arch remains intact : pedicl
widening implies post arch disruption
- less than 50% anterior body height
- compression fracture
• Unstable frx
- neurologic defisit
- loss of 50% vertebral body height
- fracture dislocation
- thoracolumbar burst frx
 Jefferson Fracture
• Pediatric frx
- frx proceeds thru open synchondroses,
and may occur w/ minimal trauma/
- posterior synchondroses fuses at age 4
- anterior synchondroses fuses at age 7
• Mechanism
- original description in 1920 noted role of
axial compression
- may also be caused by hyperextension,
causing a posterior arch fracture
• Associated injuries
- approx 1/3 of these fractures are
associated with a axis fracture
- approx 50% chance that some other
C-spine injury is present
- low rate of neurologic deficits is due to
large breadth of C1 canal
Radiographs
• Odontoid view
• Lateral view
• Flexion and extension views
• CT scan
 Dens Fracture
• Odontoid fractures are the most common
upper cervical spine fratures
• Remember rule of thirds – cervical cord
occupies a 1/3 of canal, dens occupies a 1/3
and the remaining 1/3 is empty
• Mechanism
– Flexion loading
– Extension loading
Classification
• Type I
• Type 2 Dens frx
• Type 3
Associated Injury
• Atlas frx
• Transverse ligament rupture
• Pharangeal injury
 Hangman’s frx/Traumatic
Spondylolisthesis of the Axis

• Fix of pars interarticularis of C2 & disruption of C2-C3 junction

• Type of traumatic spondylolisthesis – Hangman’s frx
• Term Hangman’s fracture is not accurate for the majority of
cases, because mechanism of injury for clinically encountered
frx often lacks large traction force present in judicial hangings
• In cases in which there is neurologic injury,
there will usually be significant horizontal
translation w/ accompanying damage to the
posterior longitudinal ligament w/ or w/o
damage of the C2 – C3 interspace
• Mechanism of injury in adults
– Judical lesion : hyperextension and distraction
– Hyperextension w/ vertical compression of
posterior column, & translation of C2 and C3
– Forceful extension of already extended neck is
most commonly described mech of injury, but
other causes include flexion of flexed neck &
compression of an extended neck
– A blow on the forehead forcing the neck into
extension is a classic mechanism of injury
producing fractures thru the pedicles of C2 known
as traumatic spondyloslishthesis of C2
 SCIWORA Syndrome
• Occurs may often in pediatric population
• Accounts for up to 2/3 of severe cervical
injuries in children < 8 years of age
• Inherent elasticity in pediatric cervical spine
can allow severe spinal cord injury to occur in
absence of x-ray findings
 Clasification spinal cord injury
• Complete
• Incomplete
• Anterior cord syndrome
• Central cord syndrome
• Brown sequad
• Cauda equina
 Anatomy
crossection spinal cord
Ascending Tract

Tracts of Goll and Burdach Proprioception,vibration,discr uncrosssed

(fasc gracilis and cuneatus imination

Dorsal and ventral Proprioception, light touch uncrossed

spinocerebellar tract

Lateral spinothalamic tract Pain, temperature crossed

Spinal olivary tract Tendon and muscle crossed

proprioception

Ventral spinothalamic tract Deep tactile and pressure crossed

sensation

Descending Tract

Lateral corticospinal tract Motor control uncrossed

(pyramidal)

Rubrospinal tract Cerebellar reflexes crossed

Lateral reticulospinal tract Inhibits locomotor conytrol crossed

Reticulospinal tract Facilittes locomotor control uncrossed

Vestibulospinal tract Postural control Uncrossed

Tectospinal tract Eye and ear reflleces crossed

 Complete / incomplete Spinal Cord
Lession
• Complete cord injury : there is complete loss of
sensation and muscle function in the body below the
level of the injury

• An injury to the upper portion of the spinal cord in

the neck can cause quadriplegia-paralysis of both
arms and both legs. If the injury to the spinal cord
occurs lower in the back it can cause paraplegia-
paralysis of both legs only.
• Incomplete lesion : there is some remaining
function below the level of the injury. In most
cases both sides of the body are affected
equally.

• Present when there is any distal sparing of

motor or sensory function along with sparing
of perirectal sensation
• Diff dx of incomplete lesions
– Central cord syndrome
– Brown sequard syndrome
– Anterior cord syndrome
– Posterior cord syndrome
– Isolated nerve root injury
– Cauda equina syndrome (w/ or w/o root escape)
– Conus medullaris injury
 Anterior Cord Syndrome
• Damage is primarily in the
anterior 2/3 of cord and is related
to vascular insuffiency
• There is sparing the posterior
columns
• Syndrome is manisfested by
complete motor paralysis
(corticospinal func) and sensory
anesthesi (spinothalamic func)
• Patient demonstrates greater
motor loss in the legs than arms
Prognosis
• anterior cord syndrome has the worst prognosis of all
cord syndromes
• prognosis is good if recovery is evident & progressive
during first 24 hours
• after 24 hrs, if no signs of sacral sensibility to pinprick
or temp are present,
prognosis for further functional recovery are poor;
only 10 to 15% of patients demonstrate functional
recovery;
 Central Cord Syndrome

• most common incomplete cord lesion

• frequently associated w/ extension injury to
osteoarthritic spine (cervical spondylosis) in
middle aged person who sustains
hyperextension injury
• cord is injured in central gray matter, & results
in proportionally greater loss of motor
function to upper extremities than lower
extremities w/ variable sensory sparing;
Anatomy:
• fibers responsible for lower extremity motor
and sensory functions are located in the most
peripheral part of the cord
• whereas fibers controlling the upper extremity
and voluntary bowel and bladder function are
more centrally located
• sacral tracts are positioned on the periphery
of the cord & are usually spared from injury;
Mechanism of Injury:
• hyperextension injury
• central cord injury and hemorrhage occur with
compression of adjacent white-matter tracts
• more peripheral positioning of lower
extremity axons within the spinal cord tracts
accounts for the injury pattern
• damage to central portion of corticospinal and
spinothalamic long tracts in white matter
produces upper motor neuron spastic
paralysis of trunk and lower extremity
 Examination
• central cord syndrome is remarkable for more
cord involvement in the upper extremities than in
the lower extremities
• manifests w/ loss of distal upper extremity pain &
temperature sensation and strength, w/ relative
preservation of lower extremity strength &
sensation
upper extremities:

 mixed upper and lower-motor-neuron lesion, w/

partial flaccid paralysis of upper extremities
(indicative of involvement of lower motor neurons)
prognosis is variable w/ poor hand function

lower extremities:
 spastic paralysis of lower extremities (indicative of
involvement of upper motor neurons)
 bladder and bowel function may also be lossed;
 Brown Sequard Syndrome

• type of incomplete cord syndrome

• injury to either side of spinal cord produces
ipsilateral muscle paralysis (from corticospinal
tract injury) and contralateral hypersthesia to
pain and temperature (from spinothalamic
injury)
• syndrome results from hemitransection of
spinal cord w/ unilateral damage to the
spinothalamic & corticospinal tracts and
resultant loss of ipsilateral motor & dorsal
column function & of contralateral pain and
temperature sensation
• often due to penetrating trauma or unilateral
facet fracture or dislocation;
 Prognosis:
• this syndrome has a good prognosis for
recovery
• more than 90% of pts regain bladder & bowel
control & ability to walk
• most patients will regain some strength in
lower extremities and most will regain
functional walking ability;;
 Cauda Equina Syndrome

• urinary retention is the most consistent

finding
• in spinal cord injuries, the caudal equina may
sustain considerable initial trauma
• in any potential cauda equina syndrome it is
important to examine for saddle anesthesia,
rectal tone, bulbocaverosus reflex, and sacral
sparing;
 Significance
• Unstable if middle column + either Anterior or
Posterior column is damaged

• Rupture of interspinous ligament is :

- associated with avulsion of spinous process
- Unstable spine
- Further flexion increases neurological injury
 Level of Spinal injury
• Neurological level is at the most lowest segment with
normal motor & sensory function

• Difficult to determine :
- as most muscle efferents receive fibres from more
than one level
- Closed cord lesions may extend over several cms.
- Dermatomes have imprecise boundaries.
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