SCI SCISCISCISCISCISCISCISCISCISCISCI.pptx

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1. Spine injury Dr Anas bitar

2. Primary Survey Airway and cervical spine control Breathing and ventilation Circulation with control of hemorrhage Disability: neurological status Exposure: completely undress the patient but avoid hypothermia

3. Incidence of SCI Incidence 2–5 per 100 000 population ~ 82% occur in men ~ 61% occur in 16-30 y Common causes MVC (48%) Falls (21%) Penetrating injuries (15%) Sports injuries (14%) sites of spinal fractures Cervical 60% Thoracic 8% Lumbar 10% Dorso lumbar 20% Sacral 2% Most common C1-C2 C5-C7 T12-L1

4. Spinal Injuries Spinal Column Injuries Injuries to Neural Structures (spinal cord, nerve roots) ± . Although the majority of spinal injuries do not affect the cord or spinal roots, about 10% will result in quadriplegia or paraplegia

5. Spinal Stability Three column theory of spinal stability by Denis Anterior : ALL, anterior annulus fibrosis,anterior half of VB Middle : PLL, posterior annulus fibrosis, Posterior half of VB Posterior : Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process Spinal stability is dependent on at least two intact columns.

6. Level Flexion/ Extension Lateral Flexion Rotation O -C1 25 5 5 C1-C2 20 5 40 C2-C3 10 10 3 C3-C4 15 11 7 C4-C5 20 11 7 C5-C6 20 8 7 C6-C7 17 7 6 C7-T1 9 4 2 Ranges of Motion

7. Cervical Traction Weights: 2.5 kg for head and 1/2 kg for each vertebra 5 pounds per spinal level above the fracture/dislocation. 2.25 kg for each level below the occiput Application: Shave the hair above the ear region Local anaesthetic Avoid masseter Avoid Temporal artery Small incision above ear in line with auditory meatus Screw in pin until it just perforates outer table skull Tie on rope Attach weights

8. For treatment within 3 hours after injury Loading dose : 30 mg/kg bolus over 15 minutes then 45 minutes pause followed by : 5.4 mg/kg/ hour for 23 h For treatment within 3 - 8 hours after injury Loading dose : 30 mg/kg bolus over 15 minutes then 45 minutes pause followed by : 5.4 mg/kg/ hour for 48 h Methylprednislone Solu-Medrol ®

9. Mechanism of Injury Flexion Extension Distraction compression Shearing rotation

10. Spinal Stabilization Techniques Head Immobilizers Cervical-Collars Backboards

11. Log rolling

12. Degrees of injury Complete: flaccid paralysis + total loss of sensory & motor functions Incomplete: Anterior sc syndrome Posterior sc syndrome Central cord syndrome Brown sequard’s syndrome Cauda equina syndrome Complete: 3% have recovery w/in 24hrs. After 24hrs no recovery

13. Neurogenic Shock Triad of : i ) hypotension ii) bradycardia iii) Hypothermia More commonly in injuries above T 6 ( Seen in cervical injuries ) Secondary to disruption of sympathetic outflow from T 1 – L 2 Loss of vasomotor tone Loss of cardiac sympathetic tone – bradycardia Blood pressure will not be restored by fluid infusion alone Massive fluid administration may lead to overload and pulmonary edema Vasopressors may be indicated Atropine used to treat bradycardia

14. Spinal Shock immediate loss of reflex ( areflexia ) below the level of injury Signs : Slow heart rate Low blood pressure Flaccid paralysis of skeletal muscles Loss of somatic sensations Urinary bladder dysfunction Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns minimal reflex activity may appear within a period of 3–4 days or may be delayed up to 6–8 weeks, the average duration being 3–4 weeks.

15. Central Cord Syndrome Most common incomplete cord syndrome. Hyperextension injury Older age with cervical spondylosis Upper extremity deficit is greater than lower extremity deficit, because the lower extremity corticospinal tracts are located lateral in the cord.

16. Brown- Sequard Syndrome may result from rotational injury such as fracture-dislocation or from penetrating trauma such as stab wound. Ipsilateral : Impaired or loss of movement, touch, pressure and vibration Contralateral : loss of pain and temperature sensation

17. Anterior Spinal Cord Syndrome Seen in flexion injuries e.g. burst fracture, flexion tear drop fracture and herniated disk. Anterior spinal artery compression Loss of power, reduced pain and temperature below the lesion This causes damage to the” corticospinal tracts …….. motor paralysis spinothalamic tracts ……. loss of pain, temperature

18. Posterior Spinal Cord Syndrome Uncommon Hyperextension injuries Loss of proprioception and vibration sense However they may experience difficulty coordinating movement of their limbs Severe ataxia Loss of positioning sense due to disruption of dorsal columns. Good prognosis. Spinal cord concussion transient loss of function Recovery usually begins within 6 hours and should be detected within 48 hours.

19. Conus medullaris syndrome : saddle anesthesia, incontinence (painless, s ymmetrical) Cauda Equina Syndrome : saddle anesthesia, incontinence (painful, as ymmetrical)

20. Spinal cord injury There are two types of injury to the spinal cord: Non-hemorrhagic with only high signal on MR due to edema. Hemorrhagic with areas of low signal intensity within the area of edema

21. Types of Spinal Cord Paralysi s Monoplegia - paralysis of one limb Diplegia - paralysis of both upper or lower limbs Paraplegia - paralysis of both lower limbs Hemiplegia - paralysis of upper limb, torso and lower leg on one side Quadraplegia - paralysis of all four limbs

22. What are the differences between UMN and LMN ? (e.g., cauda equina vs. myelopathy )

23. ASIA ( A merican S pinal I njury A ssociation ) Impairment Scale A – Complete: no sensory or motor function preserved in sacral segments S 4 – S 5 B – Incomplete: sensory, but no motor function in sacral segments C – Incomplete: motor function preserved below level and power graded < 3 D – Incomplete: motor function preserved below level and power graded 3 or more E – Normal: sensory and motor function normal

24. CERVICAL

25. C1 – C2 anatomy

26. ligaments

27. Greater occipital nerve

28. Vertebral artery

29. Approach to C spine radiograph

30. prevertebral soft tissue : C2:….6 C6:….22 Atlanto -Dental Interval (ADI): N ≤ 3 Adults N ≤ 4 Children Basion -Dental Interval (BDI): Basion to Tip of Dens……<12 mm Basion -Axial Interval (BAI): Basion to Posterior Dens…. 4-12 mm .

31. Pediatric Cervical Spine Lymphoid tissue makes soft tissues more prominent Vertebral bodies are bullet shaped C1 Synchondroses C2 Synchondroses

32. Lateral view does not show the cervico -thoracic junction Swimmer’s view shows antero-listhesis of C-6 on C-7 of > 3mm

33. 2 3 RP RT RP = retropharyngeal space RT = retrotracheal space 1 = anterior vertebral line 2 = posterior vertebral line 3 = spinolaminar line 4 = posterior spinous line 1 4 Normal Cervical Spine

34. C5/6 is the most common site.

35. Occipital Condyle Fractures rare and frequently are missed on initial evaluation Rarely diagnosed on X-Rays May present with lower cranial nerves deficits ( hypoglossal nerve palsy ) Classification ( Anderson & Montesano) Description Treatment TYPE I Comminuted cervical collar, or Halo TYPE II extension of linear basilar fracture TYPE III Avulsion of condyle Fragment External Immobilization with Halo for 2 months

36. Atlanto - Occipital Dislocation Hyperextension and distraction mechanism Down’s syndrome, RA more susceptible More common in Kids Disruption of tectorial ligaments Often fatal ( Very rare in surviving patients) rule of 12: tip of dens- basion \ Basion -post line< 12mm Atlanto -occipital condyle distance<5mm Treatment- Highly unstable avoid traction fusion occiput to C2 Atlanto -Occipital Dislocations: Normal, Anterior (Type 1), Longitudinal (Type 2), Posterior (Type 3)

37. Atlanto -axial Dislocation Hyperextension injury Children>adults Head slips forward on C1 Usually fatal Widening of the predentate space This injury is unstable Neurologic injury occurs from cord compression between the odontoid and posterior arch of C1

38. Atlas (C1) fractures Posterior Arch Fracture Anterior Arch Facture Jefferson’s Fracture Lateral mass fracture

39. Jefferson fracture Burst fracture of atlas (C1) Usually bilateral breaks in ant/ post arches Vertical compression / axial load injury Widened lateral masses of C1 on open-mouth odontoid view Widened predens space Moderately unstable Neuro deficits uncommon Associated with: Fractures of C7 (25%) Fractures of C2 pedicle (15%) Extraspinal fractures (58%)

40. Spence's Rule : If, on plain films, the distance of excursion of lateral masses is 7 mm or more, there is a transverse ligament rupture

41. Axis (C2) Fractures Hangman’s fracture Teardrop fracture Odontoid fracture

42. Odontoid fracture Type I Avulsion of tip of odontoid (5-8%) Difficult to detect; required CT Type II Fracture through base of dens (54-67%) Complication: nonunion Most common Type III Subdental injury (30-33%) Prognosis: good Anderson and d'Alonzo classification

43. Hangman's Fracture Most common fracture of C2 Bilateral fracture of pedicles of axis (C2) Anterior slip of C2 on C3 Mechanism: Sudden deceleration with hyperextension May or may not have anterior subluxation Unstable Neuro deficits variable Teardrop fracture of inferior aspect of C2 or C3 is clue

44. Classification of Hangman' s fractures Type I (65%) hair-line fracture C2-3 disc normal Type II (28%) displaced C2 disrupted C2-3 disc ligamentous rupture with instability Type III (7%) displaced C2 C2-3 Bilateral interfacet dislocation Severe instability

45. Surgical Approaches to C1-2 fusion Posterior bone and wire fusion Posterior transarticular screw fixation Posterior fusion with lateral mass screws /rods Posterior fusion with pedicle screws /rods Posterior fusion with translaminar screws /rods Anterior odontoid screw fixation Anterior transfacetal screw fixation

46. Anterior vs Posterior Approach 50% cervical rotatory excursion at C1-2 Posterior fusion eliminates atlantoaxial rotation , usually noticeable by patient Odontoid screw fixation : provides immediate stabilization, promotes bone healing, preserves C1-2 rotation Initial anterior approach morbid due to extensive neck dissection

47. Posterior C1-2 Approaches Midline incision Avascular plane Bipolar dissection /blunt dissection ( cobb and gauze) May extend superiorly to ext occipital protuberance Lateral dissection limited by vertebral arteries

48. Posterior bone and wire fusion 1

49. Autogenous iliac crest graft

50. Posterior Fusion with C1-2 Transarticular Screw Fixation 3.5mm screw through the C2 pedicle, across the C1-2 facet, and into each lateral mass of C1 C1 and 2 become rigidly coupled 2

51. C1 Lateral Mass / C2 Pedicle Screw-Rod Fixation 3

52. Posterior C1-2 Fusion with Pedicle Screws 4

53. Posterior C1-2 Fusion with Translaminar Screws First presented in 2003 at Cervical Spine Research Society Technique published in 2004 Minimize injury to vertebral artery as seen with transarticular and pedicle screws Crossing, bilateral translaminar screws 5

54. Anterior Odontoid Screw Fixation Acute fractures (6 months or less) Direct anterior odontoid screw preserves cervical rotation and offers immediate stabilization but needs intact transverse ligament 6

55. TRANSORAL 7

56. Anterolateral Retropharyngeal Approach 8

57. Case report Name: hasan Age : 65 y Fall from tree Fracutre at the base of odontoid process Fractures of the posterior arch of atlas Surgical treatment : Occipitocervical Fusion

58. Patients are placed in the prone position and secured to the surgical table using the Mayfield headholder

59. The posterior midline surgical exposure For occipitocervical fusion C1 C2 occipital

60. Optimal screw placement positions for occipital fixation Cervical Lateral Mass Screw

61. Illustration of the lateral mass screw trajectory in the axial plane Appropriate angle The screw trajectory puts the nerve root at risk.

62. Occipital Cervical Fusion Using a Posterior Occipital Plate-Rod System Attached to Polyaxial Lateral Mass Screws

63. Flexion Teardrop Fracture This fracture is the result of a combination of flexion and compression , which is usually the result of a motor vehicle accident. The teardrop fragment comes from the anteroinferior aspect of the vertebral body. The posterior part of the vertebral body is displaced backward into the spinal canal. 70% of patients have neurologic deficit. It is an unstable fracture associated with complete disruption of ligaments and anterior cord syndrome.

64. Extension teardrop fracture occurs when the anterior longitudinal ligament pulls a bony fragment away from the inferior aspect of the vertebra because of the sudden hyperextension.

65. Bilateral Facet Dislocation resulting from extreme hyperflexion injury without axial compression It is associated with a very high risk of cord damage Complete anterior dislocation of affected vertebral body by half or more of the vertebral body AP diameter " Bow tie" or " bat wing" appearance of the locked facets.

66. In Australia and Europe cervical traction under general anaesthesia has been used for closed reduction of some fracture dislocations but this has not been popular in the United States.

67. Unilateral Facet Dislocation facet joint dislocation and rupture of the apophyseal joint ligaments resulting from rotatory injury of the cervical vertebrae .

68. “ bowtie” or “butterfly” appearance of the rotated articular mass

69. Unilateral facet dislocation < half of the vertebral body shifted on the lateral view Bilateral facet dislocation > half shifted forwards extreme hyperflexion injury without axial compression rotatory injury

70. Clay- Shoveler’s Fracture fracture of a spinous process C6-T1 (C7>C6>T1) Stable fracture Hyperflexion ( shoveling snow) Sudden exertion of muscular attachment

71. Whiplash injury sudden hyperextension followed by an immediate hyperflexion of the neck that results in damage to the muscles, ligaments and tendons

72. Hyperflexion Sprain Posterior ligamentous complex tears Local pain Spasms of neck muscles Nonradiating Treat as cord injury until cleared by x-ray

73. Contraindications for emergent surgery complete SCI central cord syndrome. medically unstable patient.

74. Thoraco -lumbar

75. General considerations

76. Patient evaluation

77. stability

78. Timing of surgery

79. Epidemiology Most common site of injury is thoracolumbar junction Mechanical transition zone between rigid thoracic and more mobile lumbar Lumbar spine more prone to injury Absence of ribs, transition from kyphotic to lordotic posture, sagitally oriented facet joints

80. Anatomy T spine: made rigid by ribcage articulations ( ligamentous support); facet joints in coronal plane limit flexion/extension L spine: facet joints in sagittal plane increase flexion/extension but decrease lateral bending/rotation

81. 70% of thoracolumbar injuries do not have associated neurologic deficits Every patient with spine injury should be log-rolled every 2 hours, while maintaining the integrity of the spine, to reduce the risk of decubitus ulcer formation

82. Degree of kyphosis can be measured using Cobb Measurement

83. TLSO BRACE

84. Fracture Classification: Denis Mechanical (1st degree) may result in late kyphotic deformity . Require external or operative stabilization. Neurologic (2nd degree) retropulsion of bone fragments predispose patients to increased risk for neurologic injury. Controversy re: operative stabilization. Mechanical/neurologic (3rd degree) develop after burst fx w/ neuro deficit or fracture/dislocation. Highly unstable > require operative decompression and stabilization.

85. Fracture Classification: TLICS TLICS determination for surgery: <3 points can be treated non-operatively >5 points usually require surgical intervention = 4 points can be treated w/or w/o surgery

86. AO Classification is based on the “ two column theory” Type A : compression injuries Type B : distraction injuries Type C : rotational injuries A B C

87. Compression Fractures Stable: Isolated to body less than 50% loss of height 1 or 2 levels only Unstable: Posterior arch involved or more than 50% loss of height or more than 2 levels Look for loss of height, loss of straight or anterior concave surface of body Mechanism: FLEXION . Very common Neurologic injury: Uncommon

88. Burst Fracture Vertical compression(axial load ) Failure of anterior and middle column unstable Most common at T/L junction 17% of major spinal fractures bony fragments may be retropulsed into the canal (25% of cases) and associated fractures of the posterior elements are common..

89. AP radiograph demonstrates the increased intrapedicular distance associated with a burst fracture

90. Failure of the anterior column Middle, posterior columns intact Both anterior and middle columns fail

91. Chance Fracture high-speed accident wearing lap belts hyperflexion distraction injury to the thoracolumbar spine. Most common at T10-L2 Unstable Neurologic injury in 15%, abdominal injury in 50% (tear of mesentery, bowel injury): always CT spine AND abdomen Bowel Injury

92. two potential types of injuries: fracture through the spinous process pedicle and vertebral body Or a fracture through the end-plate with disruption of the facet joint and ligamentous structures

93. Seat belt fractures A: Injury to soft tissues only. B: Bony chance fracture. C: Mixed injury

94. Posterolateral decompression technique. A, L1 burst fracture. Pedicle, transverse process, and lateral portions of T12-L1 facet are removed after L1 root has been isolated (dotted lines) . B, Area of encroachment is exposed. C, After fragments have been undercut, they are reduced into vertebral body.

95. S pinal C ord I njury w ithout R adiographic A bnormality (SCIWORA) MRI, CT, Xrays (including flexion/extension) negative with neurologic deficit

96. Indications for surgical intervention The damage to the spinal cord occurs principally at the time of the injury and it is not surprising that there has been no evidence to show improved neurological function from acute operative decompression of the spine The following are the general indications for surgical intervention: Progression of neurological deficit An open injury from a gunshot or stab wound should be explored to remove foreign particles

97. Surgical treatment Neural Decompression Stabilization Fusion

98. Neural Decompression

99. Stabilization Pedicle screw system: Instrument two levels above and below injury Short segment stabilization (one level above and below) has high rate of construct failure Pedicles screw(s) in the fracture level effectively reduces the fixation failure of the thoracolumbar burst fractures treated with short-segment pedicle instrumentation .

100. Exposure is extended laterally to include the transverse processes Localization of the pedicular holes in the thoracic spine

101. Pedicle Entrance

102. Artist’s illustration of the difference between the anatomic (AT) and the straightforward (ST) trajectories for thoracic pedicle screw placement. The thoracic pedicle screws can either be placed parallel to the endplates (straightforward trajectory), or they can be placed parallel to the axis of the pedicle itself (anatomic trajectory).

103. Thoracolumbar Mesh

104. Fusion Long term goal of instrumentation: Maintain proper spinal alignment and stability until bone fusion occurs Without solid fusion, metallic implants eventually break

105. injury is stable or unstable…… Three -column disruption Greater than 50% collapse of anterior cortex Greater than 25° of focal kyphosis Any extent of neurologic deficit Greater than 50% canal compromise at L-1 and 80% compromise at L-5.

106. Plumb line dropped from middle of C7 vertebral body falls close to posterior superior corner of S1 vertebral body

107. E Errors in pedicle screw placement . Nerve root impingement by screw violating medial pedicle wall. Pedicle screw out inferiorly . Vascular damage by insertion of screw beyond anterior cortex.

108. Jumper's fracture fracture of the calcaneus and a lumbar spine fracture. This is called a 'jumpers fracture' or a 'lover's fracture', because it is usely seen in people jumping out of a window to escape from the police or a jealous husband. In this case it is clear that we are looking at an unstable fracture, because this is a burst fracture. Both the anterior and the middle column are disrupted. In addition there is edema in the posterior soft tissues indicating that there is also involvement of the posterior column. Notice also the marrow edema in the adjacent bodies due to the severe axial loading.

109. Surgical Techniques

110. Fracture/Dislocation (mechanism) Type/Issue Treatment C1 Jefferson’s Fracture (axial loading) 1. isolated 2. with transverse lig . rupture 3. widely diasthetic 4. with odontoid fracture 1. hard collar 2. halo 3. consider occiput-C2 fusion 4. treat according to odontoid fx C1-2 Rotatory Subluxation (twisting moment) 1. children, URI 2. Adults, tumor, trauma, infection 1. bedrest, analgesics, halter traction, soft collar. 2. traction, hard collar, halo, or C1-2 fusion depending on cause and duration Odontoid Fracture (flexion in young, extension in old) 1. Type 1 2. Type 2, <6mm displaced 3. Type 2, >6mm displaced or chronic or type 2A 4. Type 3 1. if no atlanto -occipital instability, collar x 3 months 2. Halo x 3-6 months 3. C1-2 fusion or odontoid screw 4. Halo x 6 months C2 Hangman’s Fracture (extension) 1. pars approximated 2. pars separated, reducible 3. pars separated, not reducible 1. hard collar x 3 months 2. Reduce in extension, then halo x 3 months 3. C2-3 fusion Unilateral Jumped Facet (flexion + rotation) 1. reducible 2. not reducible 3. with facet fracture 4. with disc herniation 1. reduce and halo x 3 months 2. open reduction and posterior fusion 3. open reduction and posterior fusion 4. anterior decompression, open reduction, and anterior fusion Bilateral Jumped Facet (flexion) 1. Reducible, without disc herniation 2. not Reducible, without disc herniation 3. with disc herniation 1. closed reduction, then posterior fusion 2. open anterior or posterior reduction and fusion 3. anterior discectomy , reduction and fusion Subaxial Spine Axial Loading Injuries (axial +/- flexion) 1. simple compression fracture 2. burst fx +/- tear drop fx 3. burst + posterior column fx 1. hard collar 2. anterior corpectomy and fusion 3. anterior corpectomy and fusion (+/- posterior fusion) Clay Shoveler’s Fracture (flexion) Always stable Soft collar and analgesics Anterior Avulsion Fracture (extension) Always stable Soft collar and analgesics Traumatic Instability of Cervical Spine

111. Fracture Denis Columns Involved Treatment Compression Fracture Anterior column Bracing (note that >50% vertebral body height loss or Cobb angle >30 degrees predicts worsening kyphosis ) Compression Fracture with Splaying of Spinous Processes Anterior and posterior columns Posterior instrumented fusion Stable Burst Fracture (preserved posterior longitudinal ligament) Anterior column and part of middle column If no neural compromise, treat w/ TLSO brace If canal stenosis present, retropulsed fragment may be reduced by ligamentous taxis with posterior instrumented fusion in distraction. Unstable Burst Fracture Anterior and middle columns with significant retropulsion or all three columns Anterior decompression and instrumented fusion Flexion-Distraction Seat Belt Injury (ligamentous) Middle and posterior columns Posterior reduction and instrumented fusion Chance Fracture (osseous) 2 or 3 columns but with good bone contact TLSO brace Shear Fracture Dislocation 3 columns Instrumented fusion, anterior, posterior, or both Traumatic Instability of Thoracic and Lumbar Spine

112. sexuality in Males with Spinal Cord Injury the nerves that control an erection are located in the sacral segments (S/2-S/4) of the spine. Spinal cord injuries that occur above these segments result in a loss of the ability to have psychogenic erections. The male with spinal cord injury is no longer able to achieve an erection by becoming emotionally or mentally excited however, these males may be able to have reflex erections with physical stimulation.