Spinal Trauma

Spinal trauma may involve injury to the spinal •

.column, spinal cord, or both
Over 50% o spinal injuries occur in the ■ •
cervical spine with the remainder being
divided between the thoracic spine, the
thoracolumbar junction, and the lumbosacral
.region
There are seven cervical, 12 thoracic, five lumbar, five sacral, and four •
.coccygeal vertebrae

.The cervical spine is the region most vulnerable to injury •

The thoracic spine is relatively protected due to limited mobility from support of the •
rib cage (T1–T10); however, the spinal canal through which
,the spinal cord traverses is relatively narrow in this region. Therefore •
.when injuries to this region do occur, they usually have devastating results •

The thoracolumbar junction (T11–L1) is a fairly vulnerable region as it is •

the area between the relatively inflexible thoracic region and the flexible •
.lumbar region •

The lumbosacral region (L2 and below) contains the region of the spinal •
canal below which the spinal cord proper ends and the cauda equina begins •
:Mechanisms suspicious for spinal injury •
.Diving ■ •
.Fall from > 10 feet ■ •
Injury above level of shoulders ■ •
.)cervical spine( •
.Electrocution ■ •
High-speed motor vehicle crash ■ •
.)MVC( •
Rugby or football injury ■ •
Spinal injuries can generally be classified •
:based on
Fracture/dislocation type (mechanism, ■ •
.stable vs. unstable)
Level of neurological (sensory and motor) ■ •
.and bony involvement
Severity (complete vs. incomplete spinal ■ •
.cord disability)
:Complete vs. incomplete •
Complete spinal cord injuries demonstrate no •
preservation of neurologic function distal to the level of
injury. Therefore, any sensorimotor function
.below the level of injury constitutes an incomplete injury

Sacral sparing :refers to perianal sensation, voluntary •

anal sphincter contraction,or voluntary toe flexion, and
.is a sign of an incomplete spinal cord injury
The exam should include testing o the three readily assessable long •
:spinal tracts
•

:Corticospinal tract (CST) •

.Located in the posterolateral aspect of the spinal cord ■ •
.Responsible or ipsilateral motor function ■ •
.Tested via voluntary muscle contraction ■ •
•

:Spinothalamic tract (STT) •

.Located in the anteriolateral aspect of the spinal cord ■ •
Responsible or contralateral pain and temperature sensation and ■ •
.tested as such •
•

Posterior columns
: •
.Located in the posterior aspect o the spinal cord ■ •
Responsible or ipsilateral position and vibratory sense and some ■ •
.light touch sensation •
Tested using a tuning fork and position sense of the fingers and toes ■ •
 Spinal Cord Syndromes
:Anterior cord syndrome-1 •
Pattern seen with injury to the anterior portion of the ■ •
spinal cord or with compression of the anterior spinal
.arteries (artery o Adamkiewicz)

Involves full or partial loss of bilateral pain and ■ •

temperature sensation (STT)and paraplegia (CST) with
.preservation of posterior column function
Often seen with flexion injuries ■ •

.Carries a poor prognosis ■ •

:Brown–Séquard syndrome-2 •
Pattern seen with hemisection of the spinal ■ •
cord usually secondary to a penetrating injury,
but may also be seen with disk protrusion,
.hematoma or tumor
Consists o ipsilateral loss of motor function •
(CST) and posterior columnfunction, with
contralateral loss of pain and temperature
.sensation
:Central cord syndrome-3
•
Pattern seen with injury to the central area of the spinal cord often in •
.patients with a preexisting narrowing of the spinal canal •
•
Usually seen with hyperextension injuries, its cause is usually attribute •
to buckling of the ligamentum flavum into the cord and/or an ischemic •
.etiology in the distribution of branches of the anterior spinal artery •
•
Characterized by weakness greater in the upper extremities than the •
.lower extremities, and distal worse than proximal •

Has a better prognosis than the other partial cord syndromes with a
characteristic pattern of recovery (lower extremity recovery progressing upward •
to upper extremity recovery, then the hands recover strength
:Manegment of spinal cord injuries
Always start with the ABCs of trauma resuscitation-1 •
. •
.Maintain spinal immobilization throughout the resuscitation-2 •

.Estimate level of neurologic dysfunction during the secondary survey -3 •

.Obtain appropriate diagnostic studies -4 •

.Establish early neurosurgical consultation -5 •

If blunt spinal cord injury is diagnosed, begin high-dose methylprednisone -6 •

.)must be given within 8 hours of injury and not for penetrating injury ( •
Loading dose of 30 mg/kg over 15 minutes during hour 1, followed by a -7 •
continuous infusion of 5.5 mg/kg/hr; the infusion is continued for 23 hours •
if the bolus is given within 3 hours of injury, or for 47 hours if the bolus is •
.given within 8 hours of injury •
:Cervical spine films are indicated for •
.Tenderness along cervical spine ■ •
.Neurologic deficit ■ •
.Good mechanism of injury ■ •
.Presence of distracting injury ■ •
Patients with altered sensorium ■ •
 Neurugenic shock
A state of vasomotor instability resulting from •
impairment of the descending sympathetic
pathways in the spinal cord, or simply a loss of
tone. sympathetic

Signs and symptoms: Flaccid paralysis, ■ •

hypotension, bradycardia, cutaneous
vasodilation, and a normal to wide pulse •
.pressure
 :Spinal Shock
State of flaccidity and loss of reflexes •
occurring immediately after spinal cord injury
Loss of visceral and peripheral autonomic ■ •
control with uninhibited parasympathetic
.impulses •
May last from seconds to weeks, and does ■ •
.not signify permanent spinal cord damage
Long-term prognosis cannot be postulated ■ •
.until spinal shock has resolved
Cervical Spine Fractures And
Dislocation
:General •
As mentioned above, these injuries are usually •
classified on the basis of mechanism(flexion,
extension, compression, rotation, or
combination of these)location, and/or
.stability
Imaging •
Four views of the cervical spine are obtained ■ •
(lateral, anteroposterior,oblique, and
.odontoid)
A lateral view alone will miss 10% of cervical ■ •
.spine injuries
: Jefferson Fracture •
.C1 (atlas) burst fracture ■ •
.Most common C1 fracture ■ •
Consists of a fracture of both the anterior and ■ •
.posterior rings of C1
Results from axial loading such as when the ■ •
patient falls directly on his or her head or
.something falls on the patient’s head
Consider all C1 fractures unstable even though ■ •
.most are not associated with spinal cord injury
: odontoid Fracture •

Type 1: Involves only the tip of the dens ■ •

.(stable)
Type 2: Involves only the base of the dens ■ •
.(unstable)
Type 3: Fracture through the base and body ■ •
.of C2 (generally unstable)
: Hangman’s Fracture •
Fracture of both C2 pedicles (“posterior ■ •
.elements”)
Usually due to a hyperextension mechanism ■ •
Unstable fracture; however, often not ■ •
associated with spinal cord injury because the
spinal canal is at its widest through C2
: Clay shoveler’s Fracture •
Usually a flexion injury resulting in an ■ •
avulsion of the tip o the spinous
process (C7 > C6 > T1) •
.May also result from a direct blow ■ •
 :Thoracic Spine Fractures
Most injuries occur at the junction between the relatively •
fixed upper thoracic spine and the mobile thoracolumbar
.region (T10–L5)
The spinal canal in this region is narrow and the blood ■ •
supply to this region of spinal cord is in a watershed area
Most thoracic spine fractures are caused by hyperflexion ■ •
leading to a wedge or compression fracture of the
vertebral body
Most fractures/dislocations in this area are considered ■ •
stable because of the surrounding normal bony thorax;
however, neurologic impairment resulting from injuries in
.this area is often complete
Lumbar Spine Fractures And Dislocation

.Results from axial loading and flexion •

.Potentially unstable •
.Neurologic injury is uncommon •
:Disraction or Seat -Belt Injury •
.Frequently referred to as a Chance fracture ■ •
Horizontal fracture through the vertebral ■ •
body, spinous processes, laminae,pedicles,
.and tearing of the posterior spinous ligament
Caused by an acceleration–deceleration ■ •
injury of a mobile person moving forward into
.a fixed seat belt
 Thoracic Outlet Syndrome
Subclavian artery/vein and brachial plexus •
pass through a space defined by the clavicle
.and first rib (thoracic outlet)
Vascular compromise is more common than ■ •
neurologic, Adson’s sign—loss of radial pulse
.on abduction and external rotation of the arm
Can present with T1 sensory loss, wasting of ■ •
thenar muscles
Rotating head away from affected side with •
elevation of arm producing paresthesia/pain is
suggestive of neurologic TOS. Concomitant
reduction of radial pulse suggests vascular
.TOS
:Etiologies •
Fibrous band compressing C8/T1 roots (inferior-1 •
.trunk)
”.Elongated C7 transverse process—“cervical rib-2 •

:Treatment •
Surgical lysis of fibrous band or removal of C7 •
transverse process by either transaxillary or
.supraclavicular approach to thoracic outlet