SPINAL

INJURIES
 Spinal Injuries
Related anatomy :
• Number of vertebrae : C7, T12, L5, S5, Co4
• Curvatures of the spine
• Normal spine articulations : stability of the spine
– Bony : facetal articulations
– Soft tissue : ligaments, disc, muscles
• Normal cord : canal ratio
– Cervical =1:4
– Thoracic =1:1
– Lumbar =1:2
 Spinal Injuries
Related anatomy :
Critical zone of the spine is from T4 to T9
• The spinal canal is narrowest in this region
• The blood supply is least in this area

Interference with any one of these in this area

can lead to paraplegia
 Spinal Injuries
Related anatomy :
Relationship of spinal cord segments to vertebra
• Cervical : Add 1
• Upper thoracic : T1 to T6 : add 2
• Lower thoracic : T7 to T9 : add 3
• T10 : L 1 to L2
• T11 : L 3 to L4
• T12 : L5
• L1 : sacral & coccygeal segments
 Spinal Injuries
Mechanism of Injury :
• Road traffic accident (30%)

• Fall from height

• Weight falling on back

• Gun shot wounds & violence (25%)

• Sports injuries
Stable injury:
Further displacement between
2 vertebral bodies does not
STABLE
occur due to intact stabilizing
structures.
or
UNSTABLE
Unstable injury:
Further displacement between
2 vertebral bodies can occur
injury?
due to destruction of the
stabilizing structures
jeopardizing the spinal cord.
 Denis’ 3 Column Concept

Anterior

Middle

Posterior
 Cervical Spine Anatomy
• Anterior column : Anterior longitudinal ligament +
Anterior annular ligament & Anterior half of vertebral
body

• Middle column : Posterior longitudinal ligament +

Posterior annular ligament & Posterior half of
vertebral body

• Posterior Column : Ligamentum flavum +

superior & interspinous ligaments +
intertransverse capsular ligament +
neural arch + pedicle & spinous process
 Significance
• Unstable Fracture : 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
 Spinal Injuries
Vertebral fractures :
Stable Injury :
- Vertebral components not displaced by normal
movements
- If neural elements are damaged, there is little
chance of further damage

Unstable Injury :
- Significant risk of displacement & consequent
damage to neural tissues
 Classification
Compressive
injury

Flexion
injury
Distractive Rotational
injury injury
 Flexion injury
A) Compressive flexion
- For cervical spine: caused by fall on the
back of head or blow on the back of head
- C5 to C7
- For thoraco-lumbar spine: caused by fall
from height on heels or the buttocks
- L1 commonest, followed by L2 and T12

It is a stable injury if compression of the vertebra

is less than 50% of its posterior height.
 Flexion injury
B) Distractive flexion
- Cause by car seatbelt injury
- With sudden stopping of a car, the upper part
of the body is forced forward by inertia while
the lower part is tied to the seat by the
seatbelt Chance #

It commonly results in a horizontal #

extending into the posterior elements and
involving a part of the body.
** mostly UNSTABLE injury
L1 & L3
 Flexion injury
C) Rotational flexion
- For cervical spine: Caused by a blow to the back
or side of the head
- For thoraco- lumbar junction: heavy blow onto
one shoulder causing the trunk to be in flexion
and rotation to the opposite side

** Causing fracture dislocation

Here 1 vertebra is twisted off in front of the one
below it, while dislocating, the upper vertebra
takes a slice of the body of lower vertebra with
it – HIGHLY UNSTABLE INJURY
 Extension injury
• Commonly seen in the cervical spine
– C5 - 6
– MVA: the forehead striking against the
windscreen forcing the neck into
hyperextension

Is Hangman’s # under
this category?
YES!
Hangman’s fracture
 Axial/ Vertical compression
injury
• Caused by object falling on head
• In the cervical spine: this force may results
in a burst #
– The vertebra body is crushed throughout its
vertical dimensions; a piece of bone may get
displaced into the spinal canal, causing
pressure on the spinal cord
• In the thoraco-lumbar spine: may results in
the similar # but due to wide canal at this
level, neurological deficit rarely occurs
UNSTABLE injury
 Direct injury & Indirect injury (due
to violent muscle contraction)
• RARE
• Caused by bullet injury (results in # of
spinous process or just any part of the
vertebra) or sudden violent psoas muscle
contraction (results in # of transverse
process)
 Classification: based on site of injury

Cervical region Thoraco-lumbar region

• Stable or unstable with/
without quadriplegia
• Whiplash injuries
• Pure dislocation is
common due to more
horizontally placed facet
joints
** commonest site: C5 - 7
• Stable or unstable with/
without paraplegia
• Usually dislocation
associated with # due to
more vertically placed
facet joint
** commonest site: T12 –
L1
 Spinal Injuries
Delay in diagnosis :
1 in 3 severe cervical spine injuries are not
recognized early
– head injuries, facial injury
– alcohol intoxication
– multiple injuries
– comatose patients

Any such patient should be treated as a

patient with cervical spine injury
 Spinal injuries
Clinical features
 Severe pain in spine
 Neurological deficit
– motor, sensory, bowel / bladder symptoms
 Symptoms related to other injuries
 Examination of head and face
 Examination of spine
– Tenderness over spinous process
– Defects / step / deformity in spine
• ligamentous injury
• dislocation of the spine
• gibbus
Spinal injuries
Clinical features
Spinal shock
 Flaccid paralysis
 below level of lesion
 Lastsfor 24 - 48 hrs
(can last for days / weeks)
Recovery from spinal shock
Return of
 - Anal reflex
 - Bulbocavernous reflex
 - Superficial reflex
 Bulbocavernosus reflex
• The bulbocavernosus reflex (BCR),
bulbospongiosus reflex (BSR) or "Osinski reflex" is
a polysynaptic reflex that is useful in testing for spinal
shock and gaining information about the state of spinal
cord injuries (SCI).
• The test involves monitoring internal/external anal
sphincter contraction in response to squeezing the glans
penis or clitoris, or tugging on an indwelling Foley
catheter. This reflex can also be tested electro
physiologically, by stimulating the penis or vulva and
recording from the anal sphincter. This test modality is
used in intraoperative neurophysiology monitoring to verify
function of sensory and motor sacral roots as well as
the conus medullaris.
 Spinal injuries
Clinical features : Prognostic signs
Poor
Return of superficial reflexes in absence of
any motor or sensory recovery
Good
 Rectal tone
 Anal reflex
 Great toe flexion
 Spinal injuries
Cord lesions
Complete cord lesion
 Complete paralysis below the level of injury
 The neurological deficit does not improve even
after recovery from spinal shock
 Complete neurological deficit lasting > 72 hrs

Incomplete cord lesion

 Persistence of any sensation below the level of
injury : Perianal sensation
 The neurological deficit improves after wearing
away of the spinal shock
 Spinal injuries
Cord lesions
Why is it important to know the type of injury?
 The greater the sparing of the motor and
sensory system the greater the expected
recovery
 The more rapid the recovery the greater the
amount of recovery
 When recovery ceases and a plateau is
reached, no further recovery can be expected
 Spinal injuries
Injuries to the cord
Central cord syndrome : Commonest type
 Both white & gray matter of the cord are
affected
 Preservation of bladder control & perianal
sensation
Anterior cord syndrome
 Complete paralysis & anesthesia but the
position & deep pressure sense are retained
 Spinal injuries

Injuries to the cord

Posterior cord syndrome
 Only deep pressure and position sense are lost

Brown-Sequard syndrome
 Hemi-transaction of the cord
 Ipsilateral paralysis
 Contra-lateral loss of pain sensation
 Spinal injuries
Investigations: Radiographs

Compression # : L3 C4 on C5 : Subluxation C5 on C6:Dislocation

 Spinal injuries:
Investigations

CT scan :
Myelogram : MRI : bony fragments
block : L1 L4 Burst # in canal
 Spinal Injuries
Treatment :
Carrying patient

Correct

Incorrect
 Spinal Injuries
Treatment : Cervical fracture

Minerva jacket

Halo traction brace Gardner - Wells traction Philadelphia collar

 Spinal Injuries
Thoracolumbar fracture

Spinal jacket

Postural reduction

Hyperextension brace
Spinal Injuries
Surgery :
Indications
• Recovery of paraplegia
stops or deteriorates
Dislocation D12 over L1
• Retropulsion of fragment
• Irreducible dislocation
• Facilitate rehabilitation

Burst fracture D12

 Spinal Injuries

H plates

Pedicular Screws & rods

Hartshill fixation
 Spinal Injuries
Management of paraplegia :
General care :
• Nutrition
• Management of associated injuries
Care of :
• Lungs : Hypostatic pneumonia
• Bowels : Constipation
• Bladder : UTI, UMN / LMN bladders
• Skin : Pressure sores
• Joints : Contracture
Psychological care
Rehabilitation
 Spinal Injuries
Pressure sores : Decubitus ulcers
• Any person if made to place a particular surface of
the body on a hard surface for more than 6 to 8
hours will develop a pressure sore !!!!!

Change of position :
• Six pillow technique
• Log rolling technique
 Spinal Injuries
Pressure sores : Six pillow technique
Six pillows used to keep all bony prominences
away from the couch. Bony prominences to be
guarded are :
• Occiput
• Scapulae Supine
• Sacrum position
• Heels
• Condyles of the femur
• Malleoli of the ankle Lateral
• Greater trochanter position
 Spinal Injuries
Pressure sores : Six pillow technique
Pillows placed : Supine position
1. Underneath the neck : occiput
2. At the back: below the
scapulae
3. Lower gluteal region : sacrum
4. Under the calf : heel
5. Supporting the foot : equinus
Pillows placed : Lateral position
6. Between the knees
 Spinal Injuries
Pressure sores :
Log rolling technique
• Patient is rolled over with
help of pillows in a single
piece : like a log of wood
• Pillows are placed similar
to the six pillow technique

Positioning in bed
 Spinal Injuries
Care of the bladder :
Initial care : Spinal Shock
• Overflow incontinence occurs :
catheterization of bladder advised
• After spinal shock has worn off :
• Two types of bladder functions :
depends on the level of injury
– Upper motor neuron bladder
– Lower motor neuron bladder
 Spinal Injuries
UMN bladder LMN bladder
Synonyms Automatic, Reflex, Hypertonic, Autonomous, Areflexic, Flaccid,
Neurogenic Hypotonic
Problem Failure to store Failure to empty
Causes - Spinal cord injury: After sp.shock - Spinal cord injury: During sp. shock
- Cerebro-vascular accidents - Conus Medullaris Syndrome
- Multiple Sclerosis - Cauda Equina Syndrome
- Tabes Dorsalis
- Syringomyelia
- Multiple Sclerosis

Lesion Above Sacral Micturition Center - Complete destruction of Sacral

(above S2) Micturition center – S2 or below
- Lesion involving exclusively the
peripheral innervation of bladder
Results in Small Hyper-reflexic, Overactive, Big Hypotonic Bladder (flaccid,
Little Bladder (Thimble bladder) - areflexic bladder) – FAILURE TO
INCONTINENCE EMPTY : as sphincter is competent
 Spinal Injuries
Care of the bladder : Treatment
UMN Bladder LMN Bladder
Problem Failure to Store Failure to empty

Treatment - Direct smooth muscle • Intermittent Catheter

relaxers- Ditropan • Crede manoeuver
- Anticholinergic drugs : (suprapubic pressure)
Probanthine • Valsalva manoeuver
- Drugs that stimulates • Drugs to induce
Alpha and Beta micturition : Stimulate
receptors to facilitate cholinergic (Urecholine)
storage: Ephedrine & block alpha adrenergic
(Minipress)
 Spinal Injuries
Care of the bladder :
UMN Bladder : LMN Bladder :
Reflex bladder Areflexic bladder
Emptying - Better and more - Poor emptying of
complete bladder
- Less residual urine - More residual urine
Emptying - Stimulation : inside of - Crede’s manoeuver :
facilitated thigh & lower Suprapubic pressure
abdomen
Infection Less rate of infection : Higher rate of infection :
Emptying is better with Poor emptying : more
intact local reflex arc residual urine in bladder
 Spinal Injuries
Care of the bowel :
Bowel care : trained by
• Stool softeners
• Enemas
• Abdominal exercises
Other aspects :
• Joint problems : Physiotherapy
• Psychological problems : Psychologist
• Rehabilitation