spinal Trauma.ppt
- 1. Spinal Trauma Mahmoud Saad M.D. Associate Professor Neurosurgery, Mansoura College of Medicine
- 2. Outline • Relevant Anatomy. • Epidemiology . • Mechanisms. • Types. • Clinical signs. • Radiological signs. • Management.
- 3. Anatomy
- 4. Cervical: Small vertebral bodies (lesser weight bearing). Extensive joint surfaces allows greater ROM (rot, flex, ext). Thoracic: Rib bearing vertebrae. Designed to remain stiff (minimal flex, ext). Lumbar: Weight-bearing vertebrae, houses cauda equine (min rot). Sacral: Transmits weight of body to the pelvis (no motion). Anatomy
- 5. Anatomy Spinal nerve roots pass out intervertebral foramen: • C1-7 exit above. • C8-L5 exit below. Spinal nerve: ventral (motor), dorsal (sensor): • Sensoric cells in dorsal. • Motoric cells in Ventral horn. Cauda equina: • formed by L & S nerve in the spinal canal before exiting.
- 7. 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 – Ligamentum flavum + superior and Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.
- 8. Significance • Unstable if middle column + either anterior or Posterior column is damaged. • Rupture of interspinous ligament : – Associated with avulsion of spinous process. – Unstable spine. – Further flexion increases neurological injury.
- 9. Cord Segments - Vertebral Level
- 10. Epidemiology Incidence • 11,000 new cases/year in US – 34% incomplete tetraplegia » central cord syndrome most common – 25% complete paraplegia – 22% complete tetraplegia – 17% incomplete paraplegia Demographics • Bimodal distribution – Young individuals with significant trauma – Older individuals that have minor trauma compounded by degenerative spinal canal narrowing Location • 50% in cervical spine
- 11. Most important spinal cord injury indicator… MECHANISM
- 12. Mechanisms MVA causes 50% Falls GSW Iatrogenic • It is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport.
- 13. Mechanisms • Direct injury: – Penetrating injuries to the spine, particularly from firearms and knives. • Indirect injury: – Most common cause of significant spinal damage. – Fall from a height spinal column collapses in vertical axis.
- 15. Pathophysiology • Primary injury – Damage to neural tissue due to direct trauma – Irreversible • Secondary injury – Injury to adjacent tissue due to • Decreased perfusion • Lipid peroxidation • Free radical / cytokines • Cell apoptosis – Methylprednisone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals
- 16. Associated conditions •Acute phase conditions • Spinal shock • Neurogenic shock • Associated injuries • Closed head injuries • Noncontiguous spinal fractures • Vertebral artery injury • risk factors for vertebral artery injury include • atlas fractures • facet dislocations • most people with unilateral injury remain asymptomatic • imaging • magnetic resonance angiography is least invasive method • treatment • stenting only if patient is symptomatic from basilar arterial insufficiency
- 17. Classification Descriptive • Tetraplegia • injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs • Paraplegia • injury to the thoracic, lumbar or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved • Complete injury • an injury with no spared motor or sensory function below the affected level. • patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an injury can be determined as complete • classified as an ASIA A
- 18. Descriptive • Incomplete injury – an injury with some preserved motor or sensory function below the injury level – Incomplete spinal cord injuries include: • Anterior cord syndrome • Brown-Sequard syndrome • Central cord syndrome • Posterior cord syndrome • Conus medullaris syndromes • Cauda equina syndrome
- 19. ASIA Classification 1. Determine if patient is in spinal shock • Check bulbocavernosus reflex 2. Determine neurologic level of injury • Lowest segment with intact sensation and antigravity (3 or more) muscle function strength • in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.
- 20. 3. Determine whether the injury is COMPLETE or INCOMPLETE COMPLETE defined as (ASIA - A) o No voluntary anal contraction (sacral sparing) AND o 0/5 distal motor AND o 0/2 distal sensory scores (no perianal sensation) AND o bulbocavernosus reflex present (patient not in spinal shock) INCOMPLETE defined as o Voluntary anal contraction (sacral sparing) o Sacral sparing critical to determine complete vs. incomplete o OR palpable or visible muscle contraction below injury level o OR perianal sensation present 4. Determine ASIA Impairment Scale (AIS) Grade:
- 22. Diagnosis of spinal injuries
- 23. Clinical Evaluation • Document the level of injury. • Rule out other injuries – DPL in abdominal injuries as there is paralytic ileus and absent peritioneal irritation. • Associated injuries in dorsal spine fracture are: – Renal injuries. – Chest and Sternal injuries. – Wide Mediatinum due to fracture haematoma. – Retroperitoneal injuries.
- 24. Level of Spinal injury • Neurological level is at the 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.
- 25. KEY POINTS – Every patient with a blunt injury above the clavicle, a head injury or loss of consciousness should be considered to have a cervical spine injury until proven otherwise – Every patient who is involved in a fall from a height or a high-speed deceleration accident should similarly be considered to have a thoracolumbar injury – Consider the presence of a vertebral column injury in all patients with multiple injuries – Lesser injuries also should arouse suspicion if they are followed by pain in the neck or back or neurological symptoms in the limbs
- 26. Neurological assessment • Sensation • Motor function • Reflexes • Rectal examination
- 27. Neurological Assessment: Sensory Grading scale: 0-2 0: absent 1: impaired 2: normal 3: not testable
- 28. Neurological assessment: Motor C5 :Deltoids/biceps C6 :Wrist extensors C7 :Elbow extensors C8 :Finger flexors T1 :Finger Abductors L2: Hip flexors L3: Knee extensors L4: Ankle dorsiflexors L5: Long toe extensors S1: Ankle plantar flexors Grading Scale :0 - 5 0. Total paralysis 1.Palpable or visible contraction 2.Active movement; gravity eliminated 3.Active movement: against gravity 4.Active movement: against some resistance 5.active movement: against full resistance NT: not testable
- 29. Bulbocavernosus reflex • Spinal mediated reflex : S2-S4. • Monitoring anal sphincter contraction in response to squeezing the glans penis or clitoris, or tugging on Foley catheter. • Useful in testing for spinal shock and state of spinal cord injuries (SCI) • Absence of the reflex indicates spinal shock • This is one of the first reflexes to return after spinal shock. • Lack of motor and sensory function after the reflex has returned indicates complete SCI.
- 30. Sacral Sparing • Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. • The presence of either is considered sacral-sparing. • Sacral sparing triad : Perianal sensation + rectal tone + great toe flexion • Sacral sparing : Present = Incomplete SCI Absent = Complete SCI
- 31. Degrees of injury • Complete - flaccid paralysis + total loss of sensory & motor functions. • Incomplete - mixed loss: – Anterior sc syndrome. – Posterior sc syndrome. – Central cord syndrome. – Brown sequard’s syndrome. – Cauda equina syndrome.
- 35. Neurogenic shock • Lesions above D6. • Minutes–hours (fall of catecholamines may take 24 hrs). • Disruption of sympathetic outflow from D1-L2. • Unopposed vagal tone. • Peripheral vasodilatation. • Hypotension, bradycardia and hypothermia. • BUT consider haemmorhagic shock if – injury below D6, other major injuries, hypotension with spinal fracture alone without neurological injury.
- 36. Spinal shock • Transient physiological reflex depression of cord function – ‘concussion of spinal cord’. • Loss anal tone, reflexes, autonomic control within 24-72 hr. • Flaccid paralysis bladder & bowel and sustained. • Priapism. • Lasts even days till reflex neural arcs below the level recovers.
- 37. Spinal clearance – KEY POINTS 1. Spinal immobilization is a priority in multiple trauma, spinal clearance is not 2. The spine should be assessed and cleared when appropriate, given the injury characteristics and physiological state 3. Imaging the spine does not take precedence over life saving diagnostic and therapeutic procedures
- 38. Radiology • Be thorough – adequacy, alignment, bones, cartilages and soft tissues and distances • SCIWORA in kids. • Flexion injury common in lower cervical spine. • Extension injury in upper cervical spine. • Junction of mobile & fixed part are prone to injury e.g. C7 T1 & D12 L1.
- 39. Whiplash injury • Sudden hyperextension and flexion • Increasing neck pain for the first 24 hours • Associated headache, pain radiating to both shoulders and paraesthesia in hands • Tear Anterior longitudinal ligaments → dysphagia • Forward flexion against resistance is painful • 90% are asymptomatic after 2 years
- 40. Imaging • X-ray examination of the spine is mandatory for: 1. All accident victims complaining of pain or stiffness in the neck or back or peripheral paraesthesiae 2. All patients with head injuries or severe facial injuries 3. Patients with rib fractures or severe seat-belt bruising 4. Severe pelvic or abdominal injuries 5. Accident victims who are unconscious 6. Elderly people 7. Patients with known vertebral pathology (e.g. ankylosing spondylitis)
- 41. Imaging • Minimum of movement and manipulation. • X-ray Apart from AP and lateral views: – Open-mouth views: C1 and C2 • CT structural damage of individual vertebrae and displacement of bone fragments into the vertebral canal • MRI IV discs, ligamentum flavum and neural structures – indicated for all patients with neurological signs and those who are considered for surgery
- 42. X-ray Guidelines Adequacy, Alignment Bone abnormality, Base of skull Cartilage, Contours Disc space Soft tissue
- 43. Types of bony injury
- 46. The Open Mouth View The open mouth view should visualise the lateral masses of C1 and the entire odontoid peg. Bite blocks may improve viewing. In the unconscious, intubated patient the open mouth view is inadequate and occiput to C2 CT scan is recommended.
- 47. CT Scanning Thin cut CT scanning should be used to evaluate abnormal, suspicious or poorly visualized areas on plain radiology The combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%
- 48. MRI Ideally, all patients with an abnormal neurological examination should be evaluated with an MRI scan Patients who report transient neurological symptoms but who have a normal exam should also undergo an MRI assessment of their spinal cord
- 52. Emergency treatment • ABCDE. • Keep warm. • Treat if BP<80mmHg & HR <50 bpm. • Spring loaded gardener wells calipers for traction. • H2 Antagonists & Heparin. • Methylprednisolone
- 53. Corticosteroid National Acute Spinal Cord Injury Study I, II, and III Protocols • Methylprednisolone bolus 30mg/kg infusion 5.4mg/kg/h • Infusion for 24h if bolus given within 3 hours of injury • Infusion for 48h if bolus given within 3-8 hours after injury • No benefit if >8h > 8 hr the consensus is clear that there is no indication for steroid use
- 54. Immobilization
- 55. Principles of definitive treatment • The objectives of treatment: 1. To preserve neurological function. 2. To minimize a perceived threat of neurological compression. 3. To stabilize the spine. 4. To rehabilitate the patient. • The indications for urgent surgical stabilization are: 1. An unstable fracture with progressive neurological deficit and/or MRI signs of likely further neurological deterioration 2. Controversially an unstable fracture in a patient with multiple injuries
- 56. Stable vs Unstable • Treat as unstable until proven otherwise: • Stable injuries – Vertebral components will not be displaced by normal movements. – Little risk of neural damage • Unstable injuries – There is a significant risk of displacement and consequent damage – or further damage – to the neural tissues
- 57. Spinal instability Clinical: The loss of the ability of the spine under physiologic loads to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots.
- 58. Radiological: 1. Numerous sets of radiographic criteria have been developed in an attempt to predict which patients are or will become unstable after a spinal injury. The most commonly used is the three-column model of Denis. 2. The anterior column is comprised of the remaining portions of the vertebral body and intervertebral disc, as well as the anterior longitudinal ligament. 3. Injuries with incompetence of two or three columns are inferred to be unstable. 4. The three-column theory applies to the thoracolumbar spine only.
- 59. Unstable injury Management principles • Initial management of the unstable spine consists of immobilization of the injured vertebral segment while the patient is being stabilized and other injuries are being ruled out.
- 60. 3 factors for planning management decisions: 1. Need for decompression of neural elements 2. Need to mobilize the patient as soon as possible 3. Need to stabilize the spine that is not likely to heal without surgical intervention
- 61. Indications for surgery Presence of an incomplete neurologic injury with persistent neural compression at the site of injury. • Compression may be due to indriven bone fragments, traumatic disc herniation, epidural hematoma, or persistent vertebral malalignment. • The goal of decompressive surgery is restoration of a normal spinal canal without additional injury to the neural elements.
- 62. Surgical stabilization: 1.Arthrodesis, or fusion. • To induce adjacent vertebrae above and below the injury to heal together into a solid block of bone. • Placement of bone graft between the vertebrae. (anteriorly, between adjacent vertebral bodies, or posteriorly, between adjacent laminae, facets, or transverse processes). 2. Internal fixation (instrumentation). • maintains anatomic alignment during the time it takes for fusion to occur. • implantation of some combination of wire, hooks, screws, and/or rods. • Internal fixation is not a substitute for fusion. • general principle is that all internal fixators will eventually fail if fusion does not occur.
- 63. Thank you