Spinal Cord Injury Lecture Presentation for Medical Students.

1: Upper cervical spine (skull–C2)
Craniocervical dislocation
This injury is usually caused by high energy trauma and is often fatal. The dislocation may be anterior, posterior or vertical Power’s ratio is used to assess skull translation.
Atlantoaxial instability
This is uncommon and either resolves spontaneously or with traction. Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion.
Occipital condyle fracture
This is a stable injury often associated with head injuries, and is best treated in a hard collar for 8 weeks
The system developed by the AO (Arbeitsgemeinschaft fu˝r Osteosynthesefragen) can be used to classify these fractures. There are three main injury types (A, B and C) with increasing instability and risk of neurological injury. Type A fractures involve the vertebral body.
Type B injuries have additional distraction/ disruption of the posterior elements and
Type C injuries are rotationaL.
The majority of type B and type C injuries requiresurgical stabilization.
Osteoporotic wedge compression fractures in the elderly are the most common injury in this group. Symptomatic fractures can be treated with percutaneous bone cement augmentation, known as vertebroplasty or kyphoplasty.
In trauma cases, unstable fractures are associated with significant energy transfer to the patient and may be associated with major internal injuries, such as pulmonary contusion and spinal cord injury.The thoracolumbar junction is especially prone to injury. This can vary from a minor wedge fracture to spinal dislocation.
Burst fractures are comminuted fractures of the vertebral body. Usually the distance between the pedicles is widened and bone fragments are retropulsed into the spinal Canal .
The surgical approach can be anterior, posterior or combined. For burst fractures with neurological compromise, an anterior approach with vertebral corpectomy, canal clearance and anterior reconstruction is often used.Compression Fracture
Compression fracture is a compression/ flexion injury causing failure of the anterior column only. It is stable and not associated with neurologic deficit, although the patient may still have significant pain.
Burst Fracture
Burst fracture is a pure axial compression injury causing failure of the anterior and middle columns. It is unstable, and perhaps half of patients have neurologic deficit due to compression of the cord or cauda equina from bone fragments retropulsed into the spinal canal.
Chance Fracture
Chance fracture is a flexion-distraction injury causing failure of the middle and posterior columns, sometimes with anterior wedging. Typical injury is from a lap seat-belt hyperflexion with associated abdominal injury. It often is unstable and associated with neurologic deficit.
Fracture-Dislocation
Fracture-dislocation is failure of the anterior, middle, and posterior columns caused by flexion/distraction, shear, or compression forces. Neurologica

1. Spinal Cord Injury Presenter : Dr KESHENI LEMI SUPERVISOR :ATYAM SOLOMON ,ORTHOPEDIC SURGEON

2. OUTLINE Clinical anatomy Epidemiology Risk factors\Causes Mechanism of injury\ Pathophysiology Classifications Common Fractures Clinical Features Investigations Management Complications

3. External features of spinal cord Definition : it is the lower part of the central nervous system Shape : irregular cylindrical mass Site : it lies within the vertebral canal (boney canal) Length : average 45cm in length and 1.5 cm in diameter , in adults being 25cm less than the length of the vertebral column Extension : from slightly below the foramen magnum superiorly , to the level of the lower border of the 1 st lumbar vertebra or the upper border of the 2 nd lumbar vertebra or in between (in adults)

4. Age variations in the length of spinal cord At the 3 rd month of pregnancy : it occupies the full length of the vertebral canal At full term (end) of pregnancy : it reaches the level of the 3 rd lumbar vertebra In adults : it reaches the level of the lower border of the 1 st lumbar vertebra

5. End of the spinal cord The spinal cord ends as a conical mass called ( conus medullaris ) At this site the lumbar, sacral, and coccygeal nerves are collected in a manner like the tail of the hoarse called ( cauda equina )

6. End of the spinal cord

7. Enlargements of the spinal cord The spinal cord along its course is not a complete cylindrical mass but it has two enlargements 1. Cervical enlargement : lying at the level of the lower cervical vertebrae representing the orgin of brachial plexus 2. Lumbar enlargement : lying at the level of the lower vertebrae representing the origin of lumbar plexus

8. Coverings of the spinal cord The spinal cord is covered with 3 membranous envelops called meninges arranged from superficial to deep as follows : 1. Outer covering called dura matter (fibrous membrane) 2. Intermediate covering called arachnoid matter (transparent membrane) 3. Inner covering called pia matter (vascular membrane)

9. Components of spinal nerves Each spinal nerves arises from the spinal cord by 2 roots 1. Ventral (motor) root 2. Dorsal (sensory) root The 2 roots unite at the intervertebral foramen to form a (Mixed trunk) The mixed trunk (spinal nerve) divide into : A. Ventral ramus (mixed) B. Dorsal ramus (mixed)

10. Components of spinal nerves

11. Components of spinal nerves

12. Fixation of the spinal cord The spinal cord is supported and fixed in a central position within the vertebral canal by 3 derivatives from its covering as follows : 1. Filum terminale (fix the spinal cord inferiorly to the back of coccyx) 2. Ligamenta denticulate (fix the spinal cord laterally with the dura mater) 3. Dura mater ( fix the spinal cord above with the foramen magnum and below with the intervertebral foramina)

13. Segments of spinal cord The spinal cord is divided into 31 segments 8 cervical 12 thoracic 5 lumber 5 sacral 1 coccygeal Note 1 (from each segment one pair of spinal nerves arises) Note 2 (spinal segments are not corresponding to vertebral column )

14. The three column concept of spinal stability The spinal column can be divided into three columns: anterior, middle and posterior .When all three columns are injured the spine is unstable.

15. Epidemiology of Spinal Cord Injury. The incidence and causation of spinal cord injury vary globally and reflect the demographics and industrialisation of society. Every year, around the world, between 250 000 and 500 000 people suffer a spinal cord injury according to the World Health Organization in 2013. Road traffic accidents 44% remain the leading cause of spinal cord injuries worldwide. Total spinal cord injury contributes to current burden of traumatic spinal injuries in africa 13.6 new cases per 100,000 persons. the incidence of TSCI varied from 13 per million in Botswana to 75.6 per million population in south Africa Men in the third decade of life are the most likely group to sustain serious spinal cord injury.

16. Traumatic spinal cord injury in Uganda The epidemiology of TSCI in developing countries is recognized to include transport related injuries, falls, industrial accidents and violence, including gunshot wounds.1–5 In Uganda, transport injuries typically involve head-on and roll-over crashes due to excessive speed, lax securing of unstable loads, very limited use of protective helmets and vulnerability of pedestrians to being struck when crossing busy or unlit roads.

17. Pathophysiology of spinal cord injury The primary injury This is the direct insult to the neural elements and occurs at the time of the initial injury. The secondary injury Haemorrhage , oedema and ischaemia results in a biochemical cascade that causes the secondary injury. hypotension , hypoxia , spinal instability and/or persistent compression of the neural elements. Management of a spinal cord injury must focus on minimising secondary injury.

18. CLASSIFICATION CLASSIFICATION Spinal injuries are best classified on the basis of mechanism of injury into the following types: • Flexion injury • Flexion-rotation injury • Vertical compression injury • Extension injury • Flexion-distraction injury • Direct injury • Indirect injury due to violent muscle contraction

19. SPECIFIC SPINAL INJURIES 1: Upper cervical spine (skull–C2) Craniocervical dislocation This injury is usually caused by high energy trauma and is often fatal . The dislocation may be anterior, posterior or vertical Power’s ratio is used to assess skull translation. Atlantoaxial instability This is uncommon and either resolves spontaneously or with traction . Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion. Occipital condyle fracture This is a stable injury often associated with head injuries, and is best treated in a hard collar for 8 weeks

20. Jefferson fractures (C1 ring) These injuries are associated with axial loading of the cervical spine and may be stable or unstable. Associated transverse ligament rupture may occur . Most are treated non-operatively in a collar or halo brace.

21. Odontoid fractures There are three types of Odontoid peg fracture Neurological injury is rare. The majority of acute injuries are treated non-operatively in a halo jacket or hard collar for three months . Internal fixation with an anterior compression screw is indicated. in displaced fractures Posterior C1/2 fusion is required in cases of non-union.

22. Hangman’s fracture The Hangman’s fracture is a traumatic spondylolisthesis of C2 on C3. There are four types with varying degrees of instability . Those with significant displacement or associated facet dislocation are treated operatively, usually with posterior stabilisation .

23. 2: Subaxial cervical spine (C3–C7) The pattern of lower cervical spine injury depends on the mechanism of trauma. These include wedge ( hyperflexion ), burst (axial compression), tear-drop fractures (hyperextension) and facet subluxation/dislocation (rotation and hyperflexion ). The more severe injuries are accompanied by spinal cord injury. Operative intervention may be required to decompress the spinal cord and stabilize the spine with internal fixation . Facet subluxation/dislocation ranges in severity from minor instability to complete dislocation with spinal cord injury.

24. Thoracolumbar The thoracic spine is stabilized significantly by the rib cage. The lumbar spine has comparatively large vertebrae . Thus, the thoracolumbar spine has a higher threshold for injury than the cervical spine

25. AO CLASSIFICATION The system developed by the AO ( Arbeitsgemeinschaft fu˝ r Osteosynthesefragen ) can be used to classify these fractures. There are three main injury types (A, B and C) with increasing instability and risk of neurological injury. Type A fractures involve the vertebral body . Type B injuries have additional distraction/ disruption of the posterior elements and Type C injuries are rotationaL . The majority of type B and type C injuries requiresurgical stabilization.

26. Thoracic spine (T1–T10) Osteoporotic wedge compression fractures in the elderly are the most common injury in this group. Symptomatic fractures can be treated with percutaneous bone cement augmentation, known as vertebroplasty or kyphoplasty . In trauma cases , unstable fractures are associated with significant energy transfer to the patient and may be associated with major internal injuries, such as pulmonary contusion and spinal cord injury .

27. Thoracolumbar spinal fractures (T11–S1) The thoracolumbar junction is especially prone to injury. This can vary from a minor wedge fracture to spinal dislocation. Burst fractures are comminuted fractures of the vertebral body. Usually the distance between the pedicles is widened and bone fragments are retropulsed into the spinal Canal . The surgical approach can be anterior, posterior or combined. For burst fractures with neurological compromise , an anterior approach with vertebral corpectomy , canal clearance and anterior reconstruction is often used.

28. Fracture patterns Compression Fracture Compression fracture is a compression/ flexion injury causing failure of the anterior column only . It is stable and not associated with neurologic deficit, although the patient may still have significant pain. Burst Fracture Burst fracture is a pure axial compression injury causing failure of the anterior and middle columns . It is unstable , and perhaps half of patients have neurologic deficit due to compression of the cord or cauda equina from bone fragments retropulsed into the spinal canal.

29. Fracture patterns Chance Fracture Chance fracture is a flexion-distraction injury causing failure of the middle and posterior columns , sometimes with anterior wedging. Typical injury is from a lap seat-belt hyperflexion with associated abdominal injury. It often i s unstable and associated with neurologic deficit. Fracture-Dislocation Fracture-dislocation is failure of the anterior , middle, and posterior columns caused by flexion/distraction , shear, or compression forces. Neurologic deficit can result from retropulsion of middle column bone fragments into the spinal canal, or from subluxation causing decreased canal diameter.

30. Clinical presentation of spine injuries Loss of movement (paresis/weakness, plegia/paralysis). Loss of sensation (hypoesthesia or numbness) Loss of bowel and/or bladder control (incontinence). Exaggerated reflex actions or spasms e.g. hyperreflexia. Changes in sexual function, sexual sensitivity and fertility. Pain or intense stinging sensation e.g. parathesias

31. PATIENT ASSESSMENT Basic points Advanced Trauma Life Support (ATLS) principles apply in all Cases . The spine should initially be immobilised on the assumption that every trauma patient has a spinal injury until proven otherwise . The finding of a spinal injury makes it more likely (not less) that there will be a second injury at another level . The unconscious patient Definitive clearance of the spine may not be possible in the initial stages and spinal immobilisation should then be maintained , until magnetic resonance imaging (MRI) or equivalent can be used to rule out an unstable spinal injury

32. PERTINENT HISTORY PERTINENT HISTORY The mechanism and velocity of injury should be determined at an early stage. A check for the presence of spinal pain should be made . The onset and duration of neurological symptoms should also be recorded.

33. PHYSICAL EXAMINATION PHYSICAL EXAMINATION Initial assessment The primary survey always takes precedence, followed by careful systems examination, paying particular attention to the abdomen and chest . Spinal cord injury may mask signs of intra-abdominal injury.

34. Identification of shock Three categories of shock may occur in spinal trauma: 1 Hypovolaemic shock . Hypotension with tachycardia and cold clammy peripheries. This is most often due to haemorrhage . It should be treated with appropriate resuscitation. 2 Neurogenic shock. This presents with hypotension, a normal heart rate or bradycardia and warm peripheries. This is due to unopposed vagal tone resulting from cervical spinal cord injury above the level of sympathetic outflow (C7/T1). It should be treated with inotropic support, and care should be taken to avoid fluid overload. 3 Spinal shock . There is initial loss of all neurological function below the level of the injury. It is characterised by paralysis, hypotonia and areflexia . It usually lasts 24 hours following spinal cord injury. Once it has resolved the bulbocavernosus reflex returns .

35. Neurological examination Neurological examination Level of neurological impairment The ASIA neurological impairment scale is based on the Frankel classification of spinal cord injury: • A, complete; • B, sensation present motor absent; • C, sensation present, motor present but not useful (MRC grade <3/5); • D, sensation present, motor useful (MRC grade ≥3/5); • E, normal function.

36. Motor scoring system GRADE D5ESCRIPTION No muscle contraction 1 Visible muscle contraction without movement across the joint 2 Movement in the horizontal plane, unable to overcome gravity 3 Movement against gravity 4 Movement against some resistance 5 Normal strength

37. DIAGNOSTIC IMAGING X-ray Ct scan MRI E fast Us Basic investigations Indications for C-spine Films: Tenderness Neurologic defecit Forceful Mechanism of injury Distracting injury Altered sensorium

38. Interpretation of Lateral Plain Film Mnemonic AABCS Adequacy Alignment Bones Cartilage Soft Tissue

39. Interpreting Lateral Plain Film A dequacy Should see C7-T1 junction If not get swimmer’s view or CT

40. Swimmer’s View

41. Interpreting lateral Plain Film A lignment Anterior vertebral line Formed by anterior borders of vertebral bodies Posterior vertebral line Formed by posterior borders of vertebral bodies Spino-laminar Line Formed by the junction of the spinous processes and the laminae Posterior Spinous Line Formed by posterior aspect of the spinous processes

42. Alignment

43. Bones

44. Soft tissue Nasopharyngeal space (C1) - 10 mm (adult) Retropharyngeal space (C2-C4) - 5-7 mm Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults) Extremely variable and nonspecific

45. TREATMENT The treatment of spinal injuries can be divided into three phases, as in other injuries: Phase I Emergency care at the scene of accident or in emergency department. Phase II Definitive care in emergency depart- ment , or in the ward. Phase III Rehabilitation.

46. Emergency treatment ABCDE Keep warm Treat if BP<80mmHg & HR <50bpm Gardener wells calipers for traction H2 Antagonists & Heparin Methylprednisolone 30mg/kg iv bolus over 15min immediately can use dexamethazone instead 45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in first 3 hours after the injury. 5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.

47. Care in A&E Careful manual handling especially if unconscious Jaw thrust is safer Correct gross spinal deformities Call the anesthetist if diaphragmatic paralysis or RR>35 Use flexible fibreoptic scopes in unstable fractures Ryles tube if abdominal distension causes respiratory problems. Cathetrize to avoid overstretching of detrusor muscle IV fluids – paralytic ileus in first 48hrs. Passive movements to rule out fractures Small iv doses of opiates

48. Definitive Management & Rehabilitation Spinal-Dose Steroids- Methylprednisolone Orthotic Devices e.g. Philadelphia and Miami-J collars, Cervical collars are inadequate for C1, C2, or cervicothoracic instability, thoracolumbosacral orthoses etc. Surgery- for decompression of the spinal cord and nerve roots, and stabilization of the spine. Continued Care.

49. Complications of spinal injury Organ System Complications Cardiovascular Bradycardia/ dysrhythmia, Cardiac arrest Cardiogenic pulmonary edema Pulmonary Hypoventilation/respiratory failure, Poor secretion control Acute respiratory distress syndrome, Aspiration, Pneumonia Gastrointestinal Gastric dysmotility, Adynamic ileus, Gastritis and ulceration, Pancreatitis Hematologic Venothromboembolism Neurologic Neurogenic shock, Depression, Posttraumatic stress disorder Anxiety, Autonomic dysreflexia Genitourinary Bladder dysfunction, Urinary tract infection, Priapism Integument Pressure ulceration

50. References Schwartz’s Principles of Surgery Eleventh Edition SABISTON TEXTBOOK of SURGERY The BIOLOGICAL BASIS of MODERN SURGICAL PRACTICE 21 Edition. Bailey & Love’s SHORT PRACTICE of SURGERY 28 Edition. SRB's Manual of s urgery Sri ram Bhat M MS (General Surgery) Professor and Head Department of Surgery Kastu rba Medical College Mangalore Mangaluru, Karnataka, India Honorary Surgeon Government Wenlock District Hospital Mangaluru, Dakshina Kannada, Karnataka, India e -ma ii: [email protected] 6thedit. Kenneth L. Mattox, MD David V. Feliciano, MD, Ernest E. Moore, MD, TRAUMA, 8 th edition,2017 Advanced Trauma Life Support (ATLS) 10th edition , 2018 Burden of traumatic spinalcord injury in sub saharan africa. A SCOPIING REVIEW , article by Damilola jesuyajolu publishe November 2023. SPINAL CORD INJURY ppt presentation by Mamta Toppo and N.kumari shared aguast 2020. Traumatic spinal cord injury in Uganda: a prevention stratergy and mechanism to improve home care journal article by L STOTHERS published August 2017. internet

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