Spine and Spinal Cord Injuries

William Schecter, MD

Anatomy of the Spine

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Anatomy of the spine

7 cervical vertebrae 12 thoracic vertebrae 5 lumbar vertebrae 5 fused sacral vertebrae 3-4 small bones comprising the coccyx

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Anatomy of the Spine

Cervical lordosis Thoracic kyphosis Lumbar lordosis

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Structure of the Vertebra

Anatomy of the Spine

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Spinal cord and Vertebrae

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Spine Anatomy
Disc is joint between both vertebral bodies Facet joints form intervertebral foramen through which pass the nerve roots

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Spine Anatomy
Anterior and posterior longitudinal spinal ligaments Ligaments check the motion of the vertebrae and prevent the discs from slipping out of place

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Spine Motions

Flexion

Extension

Side bend

Rotation

Mechanisms of Injury
Compression Flexion Injury Extension Injury Rotation

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Compression Injury
Vertebral body fracture Disc herniation Epidural hematoma Displacement of posterior wall of the vertebral body

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Flexion Injuries
Tearing of interspinous ligaments Disruption of capsular ligaments around facet joints Fracture of posterior elements Disruption of posterior ligaments Often unstable fractures

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Extension Injury
Tearing of anterior longitudinal ligament Separation of vertebral bodies Rupture of Disc Avulsion of upper vertebral body from disc

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Rotational Injury

Associated with unilateral facet dislocation

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Cervical Spine
7 Cervical Vertebrae C1 (Atlas) is a ring which articulates with the occiput
C1 has no body C1 has no spinous process

C2 (Axis) so named because it is the pivot on which the Atlas turns to rotate the head
The Atlas has a vertical extension, the Dens, which articulates with C1

Notice the canal for the vertebral arteries bilaterally

Dens

Jefferson Fracture

Compression of base of skull against C1 Results in cracking the ring of C1 Best seen on open mouth x-ray Notice spreading of lateral masses of C1 away From the Dens projecting up from C2 due to Disruption of C1 ring

Lateral Masses of C1

Atlantoaxial and Dens Fractures

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The result of hyperflexion or hyperextension injuries 8% of Dens Fractures associated with C1 fractures

C2 Fractures
Dens Fracture
Hyperflexion Injury

Hangman Fracture
Hyperextension Injury Bilateral Fracture of Pedicles of C2

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Fractures above C4
Associated with Paralysis of muscles of respiration Diaphragm invervated by C3-5

Fractures in the Middle of the Cervical Spine

Associated with dysfunction of upper extremities>lower extremities (Central Cord Syndrome)

Thoracolumbar Trauma
Mechanism of injury
Compression Distraction Rotation

Assessing Stability: Denis Classification

III II I
I Fracture involves The anterior 1/2 of Vertebral body Stabletermed Anterior Column
II Fracture involves the Posterior of Vertebral BodyUnstabletermed Middle Column III Fracture involves The pedicles and lamina Of the vertebrae Unstabletermed Posterior Column

Chance Fracture: Failure of all three columns due to flexiondistraction

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Compression vs Burst Fracture

Compression Fracture
Stable Failure of anterior column without injury to middle column

Burst Fracture
UNSTABLE Failure of both anterior and middle column Often a boney fragment projecting into spinal canal

Indications for Spine Surgery

Neurologic Deterioration Unstable fracture Epidural Hematoma Narrowing of spinal canal

Goals of Spinal Surgery

Decompression of Spinal Canal Stabilization of Spine

Spinal Cord Anatomy

Spinal Cord Anatomy

Spinal Cord Anatomy

Neurologic Exam: Dermatomes

C5- Deltoid C6 Thumb C7 Middle Finger C8 - Little Finger T4 Nipple T8 Xypoid T10 - Umbilicus T12 Symphysis Pubis L4 Medial aspect of leg L5 - Space between first and second toes S1 Lateral border of the foot S3 Ischial Tuberosity S4-5 Perianal region

Neurologic Exam: Myotomes

C5 Deltoid C6 Wrist Extensors C7 Elbow Extensor C8 Finger flexors T1 Little finger abduction L2 - Hip flexion L3 - Knee Extension L4 - Ankle dorsiflexin L5 - Toe extension S1 Plantar flexion

Spinal Cord Anatomy: A Brief Review Posterior

Posterior Posterior

1&2 Posterior Columns: convey Ipsilateral information about two Point discrimination, proprioceptionAnd vibratory sense 5 Lateral Spinothalamic Tract: carries Pain and Temperature Information From contralateral extremity
4 Lateral Corticospinal Tract:

Carries Motor Information from Contralateral Brain to Ipsilateral Extremity

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Afferent Sensory Tracts in the Spinal Cord

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Clinical Syndromes resulting from Incomplete Spinal Cord Injury

Central Cord Syndrome Brown-Sequard Syndrome Anterior Cord Syndrome Conus Medullaris Syndrome Cauda Equina Syndrome

Central Cord Syndrome

Motor>Sensory Loss Upper>Lower Extremity Loss Distal >Proximal Muscle Weakness Pneumonic: MUD Classically occurs with hyperextension injuries of the cervical spine
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Brown-Sequard Lesion
Loss of Ipsilateral Proprioception, Light Touch and Motor Function Loss of Contralateral Pain and Temperature Sensation Due to hemisection of the cord due to penetrating injury Incomplete lesions most common

Anterior Cord Syndrome

Loss of Motor function, Pain and Temperature Sensation Preservation of Light touch, Vibratory Sensation and Proprioception

Conus Medullaris Syndrome

Injury to sacral cord, lumbar nerve roots causing
Areflexic bladder Loss of control of bowels Knee jerk relexes preserved, ankle jerk absent Signs similar to cauda equina syndrome except more likely to be bilateral

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Cauda Equina Syndrome

Injury to nerve roots and not spinal cord itself Muscle weakness and decreased sensation inaffected dermatomes Decreased bowel and bladder control

Treatment of Acute Spinal Cord Injury

Methylprednisolone 30mg/kg as soon as possible (within the first 8 hours after injury) for proven NON-PENETRATING spinal cord injury 5.4 mg/kg/hr for the next 23 hours

Important Adjunct Measures

Frequent turning Special bed to prevent pressure sores Splint extremities to prevent flexion contracturessplints MUST be well padded to protect skin Range of motion of joints Occupational and Physical Therapy Intermittent urinary catheterization if appropriate Skin Care Avoid succinylcholine b/o induced hyperkalemia Autonomic hypersensitivity Pulmonary Embolus Prophylaxsis

Principles of Initial Management

Prevent further damage Assume a spine injury until proven otherwise

Primary Survey
Airway Breathing Circulation Disability: Moves upper and lower extremities?? Exposure

Secondary Survey
Careful Orthopedic and Neurologic Evaluation takes place in the Secondary Survey

History
Pre-injury neurologic status Mechanism of injury Review Pre-hospital report Change in neurologic status? DOCUMENT FINDINGS

Cervical Spine Injury

Cervical Spine poorly protected Suspect if:
Supraclavicular injury Maxillofacial trauma Head injury High speed injury

Clinical Clearance of Cervical Spine only if:

Patient awake and fully cooperative The neck is pain free without swelling, hematoma, pain to palpation or boney abnormalities No distracting injuries The patient has full pain free active range of motion DO NOT PASSIVELY MOVE THE PATIENTS HEAD!!!!

Initial Treatment of Possible Cervical Spine Injury

Immobilization Imaging studies
AP, lateral and open mouth spine films Consider CT MRI to view ligaments and spinal cord

Search for occult injury in patient with a neurologic deficit DOCUMENT FINDINGS Early neurosurgical/orthopedic consultation

Neurological Examination
Motor examination of upper and lower extremities Sensory Examination of upper and lower extremities
Examine perianal sensation to pinprick (S3,S4) Distinguishes between a complete and incomplete spinal cord injury

Reflexes DOCUMENT FINDINGS

Clinical Signs of Cervical Spinal Cord Injury

Areflexia Diaphragmatic Breathing Forearm flexion Response to pain above the clavicle Hypotension and bradycardia (sympathetic nervous system paralysis Priapism (paralysis of parasympathetics)

Complete vs Incomplete Spinal Cord Injury

Perianal pinprick
absent Complete Present

Spinal Cord

Incomplete

Anal Sphincter

Urethra

Bulbocavernosus Reflex

Bulbocavernosus Reflex: Present -- Complete

Spinal Shock
Temporary COMPLETE cessation of spinal cord function Occurs IMMEDIATELY after injury Complete loss of all reflexes including the bulbocavernosus Flaccidity of all muscles

Neurogenic Shock
Caused by high spinal cord injury Slow pulse Low blood Pressure Treatment
R/O Hemorrhage and other causes of hypotension Fluids, Trendelenburg Alpha adrenergic drugs

Other problems
Inadequate ventilation Change in clinical signs due to absent sensation

Frankel Classification of Spinal Cord Injury

A. Complete: no motor or sensory function B. Sensory Only: Some sensation preserved, no motor function C. Motor Useless: Some sensory and motor function but motor function not useful D. Motor Useful: Sensory function preserved. Motor function weak but useful E. Intact: Normal Sensory and Motor function

American Spinal Injury Association (ASIA) Classification

A. Complete: No sensory or motor function preserved in the sacral segments S4 & S5 B. Incomplete: Sensory but not motor function preserved below neurological level including S4 and S5 C. Incomplete: Sensory and motor function preserved below neurological level but more than half of the muscles have a grade of 3/5 or less

American Spinal Injury Association (ASIA) Classification

D. Motor function preserved below neurological level and at least half of muscles have better than grade 3/5 function E. Normal motor and sensory function BUT ASIA Grade E does not describe pain, spasticity and dysesthesia that may result from spinal cord injury

ASIA Assessment of Motor Strength

5 4+ 4 43 2 1 0 Normal Strength Submaximal movement against resistance Moderate movement against resistance Slight movement Movement against gravity but not resistance Movement when gravity eliminated Flicker of Movement No Movement
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Radiologic Evaluation of Spine

Cervical Spine
AP, Lateral and Open Mouth (to see the Odontoid) Views Swimmers View to see junction of C7 on T1 CT Scan outstanding exam to view bone anatomy and diagnose fractures Flexion/Extension views: NOT BY NONSPECIALIST

REMEMBER: THE PATIENT CAN HAVE AN UNSTABLE CERVICAL SPINE WITHOUT A FRACTURE!!!!!

Ligamentous Injury

Hyperflexion injury Disruption of posterior Longitudinal ligament

Hyperextension Injury

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CervicalSpine Film Evaluation

See all 7 vertebrae including top of D1 Check for soft tissue swelling Check for vertebral alignment
acceptable unacceptable

Evaluation of Lateral Cervical Spine Film

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MRI is the definitive imaging technique

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Summary
Assume a spine injury until proven otherwise in blunt trauma X-ray the entire axial skeleton if: (1) appropriate mechanism of injury, (2) patient unable to cooperate with exam, a spine fracture is identified Careful DOCUMENTED neurologic, orthopedic, and radiologic evaluation of spine in secondary survey Timely orthopedic and neurosurgical consultation