Always consider spine injury in multiple trauma patients.

Introduction: ~5% of brain injury patients also have spinal injury.

~25% of spinal injury patients also have at least mild brain

injury.

Distribution of spinal injuries:

55% cervical

15% thoracic

15% thoracolumbar junction

15% lumbosacral
• ~10% of cervical spine fractures have a second,
noncontiguous fracture.
 Spinal column:
Anatomy &  7 cervical vertebrae

Physiology of 


12 thoracic vertebrae
5 lumbar vertebrae
Spine:  5 sacrum vertebrae
 4 coccyx vertebrae
 Vertebra: vertebral body (weight-bearing),
intervertebral discs, longitudinal ligaments,
pedicles, lamina, facet joints, interspinous
ligaments, paraspinal muscles provide
stability.
 Most vulnerable part due to mobility and
Cervical exposure.

Spine Cervical canal is wide from foramen

magnum to lower part of C2 most patient
survive are neurologically intact on arrival.
However approx; 1/3 with upper cervical
injury above C3 die at the scene from apnea
caused by phrenic nerve denervation.
 Below C3 spinal canal narrower more
likely to cause spinal cord injuries
Pediatric Cervical Spine:
Marked differences until ~8 years:
Flexible ligaments/joint capsules
Flat facet joints
Wedged vertebral bodies slide forward on flexion
 Spine becomes adult-like by ~12 years.

 Thoracic Spine;
 Mobility much more restricted than cervical spine.
 Rib cage provides extra stability/support
 Spinal Cord Anatomy:

Spinal cord originates at caudal end of medulla (foramen magnum).

Ends near L1 vertebra as conus medullaris. In adults
Below L1 cauda equina, more resilient to injury.
Complete cord injury = no motor/sensory function below level.
 Incomplete cord injury = some motor/sensory function preserved
better prognosis.
Clinical Importance:

Early and accurate documentation of sensation and motor strength is

essential.
 Helps in tracking neurological progression and prognosis in spinal
injury.
Documentation of Spinal Cord
Injuries:
Level of Injury
Bony level: site of vertebral damage.
Neurological level: most caudal spinal cord segment with normal
sensory & motor on
both sides.
Sensory level: most caudal intact dermatome.
Motor level: lowest key muscle with strength ≥ 3/5.
Zone of partial preservation: area just below injury with some
preserved function.
 Bony & neurological levels often do not match (due to nerve root
entry course).
Severity of Neurological Deficit

Spinal cord injury can be categorized as;

incomplete or complete Paraplegia (thoracic injury).
 Incomplete or complete Quadriplegia/tetraplegia (cervical injury).
Spinal Cord Syndromes

Central Cord Syndrome

Greater motor loss in upper extremities than lower.
Varying sensory loss.
Common mechanism: hyperextension injury in patient with cervical stenosis (often
elderly, ground-level fall, face impact).
Prognosis: better than other incomplete injuries.

Anterior Cord Syndrome

Involves motor + pain/temperature pathways in anterior cord.
Clinical: paraplegia + bilateral loss of pain & temperature.
Preserved: dorsal column functions (position, vibration, deep pressure).
 Prognosis: worst among incomplete injuries.
Brown-Séquard
Syndrome:
Cause: Hemisection of spinal cord
(commonly from penetrating trauma).

Clinical features:

Ipsilateral motor loss (corticospinal

tract).

Ipsilateral loss of position sense

(dorsal column).

Contralateral loss of pain &

temperature beginning 1-2 levels
below lesion (spinothalamic tract).
 Prognosis: Even with direct cord
trauma, some recovery usually
occurs.
Types:
Fractures
Fracture-dislocations
Morphology
SCIWORA (Spinal Cord Injury Without Radiographic of Spinal
Abnormality)
Penetrating injuries
Injuries;
 Can be classified as stable or unstable.
Specific Types of Spinal Injuries of
Concern:
Cervical spine fractures
Thoracic spine fractures
Thoracolumbar junction fractures
Lumbar fractures
Penetrating injuries
1. Associated blunt carotid & vertebral vascular injuries
Cervical Spine Fractures:

Mechanisms: Axial loading, flexion, extension, rotation, lateral bending,

distraction.
Pediatric cervical spine injury:
Rare (<1% cases).
Upper cervical (C1-C4) injuries twice as common as lower cervical.
Key cervical injuries:
Atlanto-occipital dislocation.
Atlas (C1) fracture.
C1 rotary subluxation.
 Axis (C2) fractures
Atlanto-Occipital Dislocation

Mechanism: Severe flexion + distraction.

Most patients die due to brainstem destruction, apnea or have profound
neurological impairment
Patient May survive if promptly resuscitated.
 common cause of death due to shaken baby syndrome.
Atlas (C1) Fracture

Represents ~5% of acute cervical

fractures.

Up to 40% associated with C2

fractures.

Common C1 fracture is Burst

fracture (Jefferson fracture)which
involve Disruption of anterior &
posterior rings of C1 with Lateral
displacement of lateral masses.
 Fracture is best seen on an
Open-mouth view C1-
C2region and Axial CT scan.
C1 Rotary Subluxation

 It is most often seen in children.

 It presents with Persistent rotation of head (torticollis).
 Management:
 Do not force the patient to over come the rotation but Restrict motion with in
the rotated position.
 Refer for specialized treatment.


 Axis (C2) Fractures

 largest cervical vertebra prone to fractures.
 Acute fracture of C2 represents ~18% of all cervical spine injuries.
 Important types: Odontoid fractures & posterior element (Hangman’s)
fractures.
Odontoid Fractures

Involve ~60% of C2 fractures.

Odontoid = peg-shaped process projecting upward, stabilized by transverse ligament.
Types:
Type I: Tip of odontoid (rare).
Type II: Base of dens (most common).
Type III: Extends into body of axis.
 Pediatric note: <6 years epiphysis may mimic fracture.


 Posterior Element Fractures (Hangman’s Fracture)

 Involves pars interarticularis of C2.
 Mechanism: Extension-type injury.
 Management: Immobilize with rigid cervical collar until specialist care
Most flexion and extension occurs at C5-C6 thus
most vulnerable to injury.
In Adults Most common fracture level is C5 and
Most common subluxation occurs C5 on C6. Cervical
Spine
Other injuries:
Fractures &
Subluxation of articular processes
(unilateral/bilateral locked facets). Dislocations



Fractures of laminae,
(C3-C7):
spinous processes, pedicles, lateral masses.
 Ligamentous disruption (rare, without
fracture/dislocation).
Thoracic Spine Fractures:

Classified into 4 categories:

1. Anterior wedge compression injuries.
2. Burst injuries.
3. Chance fractures.
 4. Fracture-dislocations.
Thoracolumbar Junction Fractures
(T11-L1):
Occur due to immobility of the thoracic spine vs lumbar spine.
Common mechanism: acute hyperflexion + rotation and usually unstable.
At-risk groups:
Fall from height.
 Restrained drivers with severe flexion with high kinetic energy transfer.


 Cord ends at conus medullaris (L1) injuries often cause:

 Bladder & bowel dysfunction.
 Lower extremity weakness & sensory loss.
1. Patients highly vulnerable to rotational movement extreme care when
logrolling them.
 Radiographic signs similar to thoracic
Lumbar & thoracolumbar fractures.
 Involves cauda equina (not spinal
Fractures: cord) deficit. Lower likelihood of
complete neurological
Penetrating Injuries:

Often cause complete neurological deficit due to path of missile

involved (bullet/knife).
Deficits may also occur from energy transfer of high-velocity missiles
passing near the cord.
 Usually stable unless a significant portion of the vertebra is
destroyed.
Blunt Carotid & Vertebral Artery
Injuries:
Caused by blunt trauma to the neck.
Early recognition & treatment reduce risk of stroke.
Spinal indications for screening include:
C1-C3 fractures.
Cervical spine fracture with subluxation.
Fractures involving the foramen transversarium.
 Careful clinical exam + radiographic assessment are essential.
Imaging & Evaluation:

Cervical spine: MDCT preferred; if not → x-rays (AP,

lateral, odontoid view)
Thoracic & Lumbar spine: CT preferred; AP/lateral x-rays
alternative
• MRI: for soft tissue, cord contusion, ligamentous injury
General Management of
Spine/Spinal Cord Trauma:
Restrict spinal motion.
IV fluids as supportive care.
Medications as indicated.
 Transfer to specialized care when appropriate.
Specific Management of Spinal Cord Injuries:
1.Emergency Management

 Immobilization: Immediately stabilize the spine to prevent further

injury using cervical collars, backboards, or braces.
 Airway, Breathing, Circulation (ABCs): Maintain airway and
breathing; provide oxygen or mechanical ventilation if needed.
 High-dose steroids (controversial): Methylprednisolone was once
standard within 8 hours post-injury to reduce inflammation but is now
debated due to side effects.
2. Medication:

 Neuroprotection: Attempts to protect nerve cells from secondary

injury (research ongoing).
 Medications: Pain control, muscle relaxants, anticoagulants to
prevent clots, and bowel/bladder management drugs.
 Management of complications: Prevent infections, pressure ulcers,
autonomic dysreflexia.
4. Surgical Management

Indications:
Progressive or severe neurological deficit.
Cord compression (fracture, hematoma, disc).
Mechanical instability (burst fracture, fracture–dislocation).

 Procedures:
 Anterior cervical decompression and fixation,
 transpedicular screw fixation.
 Lateral Mass scriew fixation.
 Goal: Early decompression & stabilization to allow mobilization and
rehabilitation.
4.Rehabilitation;

 Physical therapy: To improve strength, mobility, and prevent muscle atrophy.

 Occupational therapy: Focuses on daily living skills.
 Psychological support: Counseling to help with emotional and psychological impact.
 Assistive devices: Wheelchairs, braces, and other aids.

 5. Experimental/Advanced Therapies (Under Research)

 Stem cell therapy
 Neuroregenerative techniques
 Electrical stimulation
 Exoskeletons
Spinal Motion Restriction in the ED:

Prevent spinal movement above and below suspected injury until

fracture is excluded.
Place patient supine on a firm surface with a properly sized rigid cervical
collar.
 Maintain spinal motion restriction until injury is excluded.
Special Considerations:

Do not reduce obvious deformities.

Children may present with torticollis.
Elderly may have degenerative kyphosis.
Leave patients in position of comfort while restricting motion.
Obese patients: cervical collars may not fit
Do not force alignment if it causes pain.
 Use bolsters & padding for support.
Cervical Collar & Spine Board

Semirigid collars do not fully restrict motion.

Supplement with bolsters & straps for better restriction.
 Long spine boards are recommended only for extrication & rapid
movement, not prolonged immobilization
Logroll Maneuver: