Spinal Injuries

• Less common than

traumatic injuries of the
extremities but:
– Have the lowest functional
outcomes and the lowest rates
of return to work after injury
in all major organ systems.
 Major Trauma
•High energy trauma.
•Polytrauma patients.
•Neurological involvement.
 Cervical Spine Injuries
• Account for one-third of all spinal injuries.
• The most commonly injured vertebrae(1) are:
– C2: where one-third of which are odontoid
fracture.
– C6,C7: are the most frequently affected
levels in the subaxial spine (vertebral body
fracture)
• A neurological injury occurs in about 15% of
spine trauma patients.
 Normal Anatomy
• Functionally, the cervical spine is divided into:
– The upper cervical spine [occiput (C0)–C1–C2]
– The lower (sub-axial) cervical spine (C3–C7).
 Biomechanics of Cer vical Spine
Trauma
• The conditions under which neck injury occurs
include several key variables such as:
– impact magnitude.
– impact direction.
– point of application.
– rate of application.
 Biomechanics of Cervical Spine
Trauma
• For example in lower cervical spine:
• Vertical loading of the lower cervical spine in
the forward flexed position
reproduce pure ligamentous injuries.
• This mechanism produced bilateral dislocation
of the facets without fracture.
• A unilateral dislocation was produced if lateral
tilt or axial rotation occurred as well.
 Biomechanics of Cervical Spine
Trauma
• Axial loading less than 1 cm anterior to the
neural position produced anterior
compression fractures of the vertebral body.
• Burst fractures can be produced by
direct axial compression of a slightly flexed
cervical spine.
• Tear-drop fracture results from
a flexion/compression injury with disruption
of the posterior ligaments.
 Spinal Cord Injury

• It is now well accepted that acute spinal cord

injury (SCI) involves both:
– Primary injury mechanisms.
– Secondary injury mechanisms.
 Spinal Cord Injury
• The primary injury of the spinal cord results
in local deformation and energy
transformation at the time of injury and is
irreversible.
• It can therefore not be repaired by surgical
decompression.
• The injury is caused by:
– bony fragments.
– acute spinal cord distraction.
– acceleration-deceleration with shearing.
– laceration from penetrating injuries.
 Spinal Cord Injury

• Immediately after the primary injury,

secondary injury mechanisms may initiate,
leading to delayed or secondary cell
death that evolves over a period of days to
weeks.
• These secondary events are
potentially preventable and reversible.
 Spinal Cord Injury
• In the case of a lesion of the cord cranial to T1, a
complete loss of sympathetic activity will develop
that results in loss of compensatory
vasoconstriction (leading to hypotension) and
loss of cardiac sympathetic activation (leading to
bradycardia).
• Secondary deteriorations of spinal cord function
that result from hypotension and inadequate
tissue oxygenation have to be avoided.
 Spinal Cord Injury
• Injuries to the spinal cord often result in
spinal shock.
• The phenomenon of spinal shock is
usually described as:
– loss of sensation
– flaccid paralysis
– absence of all reflexes below the spinal cord injury.
• It is thought to be due to a loss of
background excitatory input from supra-spinal
axons
 Spinal Cord Injury
• Spinal shock is considered the first phase of
the response to a spinal cord injury, hyper-
reflexia and spasticity representing the
following phases.
• When spinal shock resolves, reflexes will
return and residual motor functions can be
found.
 History
• The cardinal symptoms of an acute
cervical injury are:
– pain
– loss of function (inability to move the head)
– numbness and weakness
– bowel and bladder dysfunction.
 History
• In patients with evidence for neurological deficits, the
history should include:
– time of onset (immediate, secondary)
– course (unchanged, progressive, or improving)

• The history should include a detailed assessment of the

injury:
– type of trauma (high vs. low-energy)
– mechanism of injury (compression, flexion/
distraction,
hyperextension, rotation, shear injury)
 Initial Management
• Primary survey
• A full general and neurological assessment must
be undertaken in accordance with the principles
of advanced trauma life support (ATLS).
• Spinal trauma is frequently associated with
multiple injuries.
• As always, the patient’s airway, breathing and
circulation (“ABC”—in that order) are the first
priorities in resuscitation from trauma.
 Initial Management
• Secondary survey
• Once the immediately life-threatening injuries
have been addressed, the secondary (head
to toe) survey that follows allows other
serious injuries to be identified.
• If neurological symptoms or signs are present,
a senior doctor should be present and a
partial roll to about 45˚ may be sufficient.
 Initial Management
• Secondary survey
• specific signs of injury including:
– local bruising
– deformity of the spine (e.g. a an increased
gibbusor interspinous gap)
– vertebral tenderness.
• The whole length of the spine must be palpated,
another spinal injury at a different level.
• Priapism and diaphragmatic breathing invariably indicate
a high spinal cord lesion.
• The presence of warm and well-perfused peripheries in
a hypotensive patient should always raise the possibility
of neurogenic shock attributable to spinal cord injury in
the differential diagnosis.
 Initial Management
• Secondary survey
• At the end of the secondary survey, examination
of the peripheral nervous system must not be
neglected.
• Diagnosis of intra-abdominal trauma often
difficult because of:
– impaired or absent abdominal sensation
– absent abdominal guarding or rigidity,
because of flaccid paralysis
– paralytic ileus
 Neurological assessment
• In spinal cord injury the neurological examination must
include assessment of the following:

– Sensation to pin prick (spinothalamic tracts)

– Sensation to fine touch and joint position sense (posterior
columns)
– Power of muscle groups according to the Medical Research
Council scale (corticospinal tracts)
– Reflexes (including abdominal, anal, and bulbocavernosus)
– Cranial nerve function (may be affected by high cervical
• injury).
 Neurological assessment
• By examining the dermatomes and myotomes, the
level and completeness of the spinal cord injury and
the presence of other neurological damage such as
brachial plexus injury are assessed.
• The last segment of normal spinal cord function, as
judged by clinical examination, is referred to as the
neurological level of the lesion.
• This does not necessarily correspond with the level of
bony injury, so the neurological and bony diagnoses
should both be recorded. Sensory or motor sparing
may be present below the injury.
 Neurological assessment
• The differentiation of a complete and
incomplete paraplegia is important for the
prognosis.
• It is mandatory to exclude a spinal shock
which can mask remaining neural function
and has an impact on the treatment decision
and timing.
• The first reflex to return is the
bulbocavernosus reflex in over 90%of cases.
 Neurological assessment
No voluntary sensory (sacral sparing) or motor
sparing
bulbocavernosus
reflex is present

spinal shock is resolved, and a complete cord

lesion is confirmed.
 Standard Radiographs
• Atleast three views are recommended for
alert and stable trauma patients:
– anteroposterior view
– cross-table lateral view
– open-mouth dens view
 Standard Radiographs
• Oakley introduced a simple system (radiological
ABC) for analyzing plain films:
– A1: appropriateness: correct indication and right
patient
– A2: adequacy: extent (occiput
to T1, penetration, rotation/projection)
– A3: alignment:
• anterior aspect of vertebral bodies,
• posterior aspect of vertebral bodies,
• spinolaminar line (bases of spinous process),
• tips of spinous process,
• craniocervical and other lines and relationships
– B: bones
– C: connective tissues:
• pre-vertebral soft tissue,
• pre-dental space,
• intervertebral disc spaces,
• interspinous gaps
 Standard Radiographs
• The most common causes of missed cervical
spine injury are:
– not obtaining radiographs
– making judgments on technically suboptimal
films

The latter cause most commonly occurs at

the cervico-occipital and cervico-thoracic
junction levels.
 Standard Radiographs
• For the upper cervical spine, White and Panjabi
suggested criteria indicative of instability based
on conventional radiography.
Standard Radiographs
 Computed Tomography
• CT is the first choice for unconscious
or polytraumatized patients.
– the ease of performance,
– speed of study,
– the greater ability of CT to detect fractures other than
radiography.
• The craniocervical scans should be of a
maximum 2 mm thickness, because dens
fractures can even be invisible on 1-mm slices
with reconstructions
 Computed Tomography
• Computed tomography scans are sensitive
for detecting characteristic fracture patterns
not seen on plain films:
– the mid-sagittal fracture through the posterior
vertebral wall and lamina.
– rotatory instability at the atlantoaxial joints.
– shows if the dens separates from the anterior arch of
C1 with increased rotation.

• Importantly, all the injuries that were missed

by plain films required treatment.
 MRI
• Magnetic resonance imaging is the imaging study
of choice to exclude discoligamentous injuries, if
lateral cervical radiographs and CT are negative.
• MRI is the modality of choice for evaluation of
patients with neurological signs or symptoms to
assess soft tissue injury of the cord, disc and
ligaments.
• Particularly, STIR sequences are very helpful in
visualizing posterior soft tissue injuries and
thereby helping to diagnose unstable fractures
(especially if conservative treatment is decided)
MRI
 General objectives of treatment
• restoration of spinal alignment
• preservation or improvement of neurological
function
• restoration of spinal stability
• restoration of spinal function
• resolution of pain
 Non-operative Treatment Modalities
• Cervical orthoses limit movement of the cervical
spine by buttressing structures at both ends of
the neck, such as the chin and the thorax.
• However, applied pressure over time can lead to
complications such as:
– pressure sores and skin ulcers
– weakening and atrophy of neck muscles
– contractures of soft tissues
– decrease in pulmonary function
– chronic pain syndrome
 Non-operative Treatment Modalities
• Collars
– Soft collars

– The Philadelphia collar.

– Disadvantages of the
Philadelphia collar are the
lack of control for
flexion/extension control in
the upper cervical region
and lateral bending and
axial rotation.
 Non-operative Treatment Modalities
• Minerva Brace/Cast
– A Minerva cervical
brace is a
cervicothoracal orthosis
with
mandibular, occipital
and forehead contact
points.

• This brace provides adequate immobilization between C1

and C7, with less rigid immobilization of the occipital-
C1 junction.
• The addition of the forehead strap and occipital flare assists
in immobilizing C1–C2.
 Non-operative Treatment Modalities

• Traction:
– The Gardner-Wells tongs can be applied using
local anesthesia.
– The pin application sites should be a finger
breadth above the pinna of the auricle of
the ear in line with, or slightly posterior to,
the external auditory canal.
– Rule out atlanto-occipital dislocation or
discoligamentous disruption before
applying traction.
 Non-operative Treatment Modalities
• Halo
– The halo vest is the
first conservative
choice for unstable
lesions.
– Its clinical failure is
due to:
• pin track problems
• accurate fitting of the
vest
• a lack of patient
compliance
 Occipital Condyle Fracture
• This type of fracture is a rare injury.
• They often are discovered on a head CT scan in
an unconscious patient; cervical radiographs
rarely show these fractures.
• Conscious patients complaining of an occipital
headache should be suspected of having an
occipital condyle fracture until proven otherwise.
• Though cranial nerves IX-XII are sometimes
affected, neurological examination is often
normal.
Occipital Condyle Fracture
 Atlanto-occipital Dislocation
• Rare survivors usually have a
neurological deficit, particularly with cranial
nerves VII to X.
• Frequent diagnosis is at autopsies
following death related to a spinal injury.
• High-resolution CT efficiently illustrates
the injury.
• Treatment includes closed reduction
and surgical stabilization—often occiput to C2.
 Atlanto-occipital Dislocation
• Traynelis et al. classification:
– Type I: anterior dislocation.
– Type II: vertical dislocation.
– Type III: posterior dislocation.
Atlanto-occipital Dislocation
Occiput to C2 Fixation
 Fractures of the Atlas
• Fractures of the atlas account for
approximately 1–2% of all fractures.
• These fractures are frequently associated with
other cervical fractures or ligamentous
traumatic injuries.
• Burst fractures of the atlas are caused by
massive axial loads.
Fractures of the Atlas
 Fractures of the Atlas
• The does not treatment
literature to allow given on scientific
recommendations solid
evidence. be
• It is recommended to treat isolated fractures of the
atlas with intact transverse alar ligaments (implying
C1–C2 stability) with cervical immobilization alone.

• It is recommended to treat isolated fractures of the

atlas with disruption of the transverse ligament with
atlantoaxial screw fixation and fusion (a Magerl C2 and
C1 transfacet screw fixation technique).
 Atlantoaxial Instabilities
• Atlantoaxial instability results from either:
– a purely ligamentous injury or
– avulsion fractures.
• While atlantoaxial dislocation and subluxation
is relatively common in patients with
rheumatoid arthritis, a traumatic origin due to
a rupture of the transverse ligament is rare.
 Atlantoaxial Instabilities
• These injuries are significant, because
complete bilateral dislocation of the articular
processes can occur at approximately 65° of
atlantoaxial rotation.
• When the transverse ligament is intact, a
significant narrowing of the spinal canal
and subsequent potential spinal cord
damage is possible
 Atlantoaxial Instabilities
• With a deficient transverse ligament,
complete unilateral dislocation can occur at
approximately 45° with similar consequences.

• In addition, the vertebral arteries can be

compromised by excessive rotation which
may result in brain stem or cerebellar
infarction and death.
 Atlantoaxial Instabilities
• Atlantoaxial instabilities can be
classified according to the direction of the
dislocation as:

– anterior (transverse ligament disruption,

dens or Jefferson fracture)
– posterior (dens fracture, see Fielding Type IV)
– lateral (lateral mass fracture of C1, C2, or
unilateral alar ligament ruptures)
– rotatory (see Fielding Types I–III)
– vertical (rupture of the alar ligaments and
tectorial membrane)
 Atlantoaxial Instabilities
• Rotatory Atlantoaxial Instability

• A special form of atlantoaxial instability which may

occur with or without an initiating trauma.
• This subluxation is more common in children than in
adults.
• Non-traumatic etiologies include:
– juvenile rheumatoid arthritis
– surgical interventions such as tonsillectomy or
mastoidectomy
– infections of the upper respiratory tract
(“Grisel
syndrome”).
 Atlantoaxial Instabilities
• According to Fielding et al. four types can be
differentiated:
 Dens Fractures
• The most common axis injury is a fracture
through the odontoid process.
• Translational motion of C1 on C2 is restricted
by the transverse atlantal ligaments that
center the odontoid process to the anterior
arch of C1.
• With a fracture of the odontoid process,
restriction of translational atlantoaxial
movement is lost.
 Dens Fractures
• According to the
classification of Anderson
and D’Alonzo:
– Type I: oblique fractures
through the upper
portion of the odontoid
process.
– Type II: across the base of
the odontoid process
at the junction with the
axis body.
– Type III: through the
odontoid that extends into
the C2 body.
 Dens Fractures
• A variety of non-operative and operative treatment
alternatives have been proposed for odontoid fractures
based on:
– fracture type
– degree of (initial) dens displacement
– extent of angulation
– patient’s age

• Type II and Type III odontoid fractures should

be considered for surgical fixation in cases of:
– dens displacement of 5 mm or more
– dens fracture (Type IIA)
– inability to achieve fracture reduction
– inability to achieve main fracture reduction with external
immobilization
Dens Fractures
Dens Fractures
Dens Fractures
 Dens Fractures

• Anterior transarticular screw fixation: As an augmentation of

the anterior dens screw or in cases of a salvage procedure.
• Screws can be inserted over Kirschner wires from a medial-
anterior-caudal to a lateral-posterior-cranial direction
crossing the atlantoaxial joint.
Dens Fractures
 Traumatic Spondylolisthesis of the Axis
• Traumatic fractures of the posterior elements
of the axis may occur after hyperextension
injuries as seen in:
– motor vehicle accidents,
– diving,
– Falls,
– judicial hangings.
• Therefore, the term “hangman’s fracture” was
coined by Schneider in 1965.
 Traumatic Spondylolisthesis of the Axis
• Effendi et al. described three
types of fractures which are
mechanism based:
– Type I:
• isolated hairline fractures of the
ring of the axis with
minimal displacement of the
body of C2.
• These injuries are caused by axial
loading and
hyperextension.
 Traumatic Spondylolisthesis of the Axis
• Type II:
• displacement of the anterior
fragment with disruption of
the disc space below the axis.
• These injuries are a result of
hyperextension and rebound
flexion.
• Type IIA:
• displacement of the anterior
fragment with the body of the axis
in a flexed position without C2–C3
facet dislocation.
 Traumatic Spondylolisthesis of the Axis
• Type III:
– displacement of the
anterior fragment
with the body of the
axis in a flexed
position in
conjunction with C2–C3
facet dislocation.
– These injuries are caused
by primary flexion and
rebound extension.
 Traumatic Spondylolisthesis of the Axis
• Most patients with traumatic spondylolisthesis
reported in the literature were treated with cervical
immobilization with good results.

• Most traumatic spondylolisthesis heals with 12 weeks

of cervical immobilization with either a rigid cervical
collar or a halo immobilization device.

• Surgical stabilization is a preferred treatment option in

cases with:
– severe angulation (Effendi Type II)
– disruption of the C2–C3 disc space (Effendi Type II and III)
– inability to establish or maintain fracture alignment with
external immobilization.
Traumatic Spondylolisthesis of the Axis
 Subaxial Cervical Trauma
• Common.

• Usually Cx-Th junction fracture is missed in

diagnosis if no appropriate X-rays are ordered.

• There are many controversy on the best line of

treatment.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of compression–flexion injuries.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of vertical compression injuries.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of distraction–flexion injuries.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of compression–extension injuries.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of distraction–extension injuries.
 Subaxial Cervical Trauma
• Allen and Ferguson classification of lateral flexion injuries.
 Subaxial Cervical Trauma
• Cervical Spine Injury Severity Score:
• The Cervical Spine Injury Severity Score (CSISS)
is based on independent analysis of
four columns (anterior, posterior, right
column, and left lateral column).
 Subaxial Cervical Trauma
• Anderson and colleagues assessed reliability
of this classification.

• They found construct validity was also good as

all patients with scores equal to 7 had surgery.

• They found a significant correlation with high

CSISS scores (>11) to a posterior or combined
anteroposterior approach.
 Subaxial Cervical Trauma
• Subaxial Cervical Spine Injury Classification

• The Subaxial Cervical Spine Injury

Classification system (SLIC) evaluates:
– fracture morphology,
– the discoligamentous complex,
– neurologic function.

• Creating a comprehensive system to

aid treatment decision making
Subaxial Cervical Trauma
 Subaxial Cervical Trauma
• Anterior Column Injuries
• Anterior column injuries include:
– Compression fractures,
– Burst fractures,
– Flexion axial loading injury.
– Disc distraction injuries.

– Transverse process fractures are included in this group,

although they have no effect on spinal stability but
may be associated with vertebral artery injury.
Anterior Column Injuries
Anterior Column Injuries
 Subaxial Cervical Trauma
• Posterior Column Injuries

• Isolated injuries to the posterior column are less

common than those that are combined with
other fractures.

• Isolated injuries include:

– spinous process and lamina fractures.
– Disruption of the posterior complex
ligamentous without facet subluxation.
Posterior Column Injuries
Posterior Column Injuries
 Subaxial Cervical Trauma
• Lateral Column Injuries
• Injuries to the lateral column are being recognized
more frequently, likely due to better restraint systems
that are preventing the more serious injuries and by
increasing recognition from the use of diagnostic CT.
• Anatomically the lateral column consists of the lateral
masses with their superior and inferior articular
process projections.
• Lateral column injuries include:
– isolated facet fractures without subluxation,
– lateral mass fractures,
– unilateral and bilateral dislocation with and without
fractures.
Lateral Column Injuries
Lateral Column Injuries
Subaxial Cervical Trauma
Subaxial Cervical Trauma
Subaxial Cervical Trauma
Subaxial Cervical Trauma