SPINAL INJURIES. Thoracolumbar and Cervical

Spinal injuries

1. SPINAL INJURIES Dr. M SANTOSH BABU ASSISTANT PROFESSOR

2. CONTENTS RELEVANT ANATOMY BIOMECHANICS OF INJURY CLASSIFICATION CLINICAL FEATURES EXAMINATION INVESTIGATIONS TREATMENT

3. INTRODUCTION Fractures and dislocations of the spine are serious injuries because they may be associated with damage to the spinal cord or cauda equina. Thoraco-lumbar segment is the commonest site of injury; lower cervical being the next common. About 20 per cent of all spinal injuries result in a neurological deficit in the form of paraplegia in thoraco-lumbar spine injuries or quadriplegia in cervical spine injuries. Often, the patient does not recover from the deficit, resulting in prolonged invalidism or death.

4. RELEVANT ANATOMY STRUCTURE : The vertebral column consists of 33 vertebrae (7 cervical, 12 dorsal, 5 lumbar, 5 sacral and 4 coccygeal) joined together by ligaments and muscles. Each vertebra consists of an anterior body and a posterior neural arch. Each vertebral body has a central part of cancellous bone and a peripheral cortex of compact bone. The margins of the upper and the lower surfaces of the vertebral body are thickened to form vertebral rings. The neural arch is constituted by pedicles, laminae, spinous process and articulating facets.

5. RELEVANT ANATOMY

6. RELEVANT ANATOMY Between any two vertebrae is a strong ‘cushion’– the intervertebral disc. It consists of two portions, a central nucleus pulposus and a peripheral annulus fibrosus. The nucleus pulposus is a remnant of the notochord and is made up of muco-gelatinous material. The annulus fibrosus is made up of fibrous tissue and surrounds the nucleus pulposus. ARTICULATION : The entire vertebral column has similar articulation (except atlanto -axial joint). The vertebral bodies are primarily joined by intervertebral discs. Anteriorly, the vertebral bodies are connected to one another by a long, strap-like, anterior longitudinal ligament and posteriorly by a similar posterior longitudinal ligament.

7. RELEVANT ANATOMY The neural arches of adjacent vertebrae articulate through facet joints. These are synovial joints with a thick capsule. The adjacent laminae are joined together by a thick elastic ligament, the ligamentum flavum. Interspinous ligaments connect the adjacent spinous processes. The supraspinous ligament connects the tips of the adjacent spinous processes. Inter-transverse ligaments connect the adjacent transverse processes. These ligaments are together often termed the posterior ligament complex.

8. RELEVANT ANATOMY The direction and size of the articular facets forming the facet joints is different in different parts of the spine. In the cervical spine, they are short and more horizontally placed, becoming stouter and more vertical lower down the vertebral column. The facets of the lumbar spine are stout and vertically placed, hence pure dislocation (without associated fracture) does not occur in this region.

9. BIOMECHANICS OF INJURY MODE OF INJURY : A fall from height, e.g., a fall from a tree, is the commonest mode of sustaining a spinal injury in developing countries. In developed countries, road traffic accidents account for the maximum number. Other modes are: fall of a heavy object on the back e.g., fall of a rock onto the back of a miner, sports injuries etc . STABLE AND UNSTABLE INJURIES : For purpose of treatment, it is crucial to assess the stability of an injured spine.

10. BIOMECHANICS OF INJURY A stable injury is one where further displacement between two vertebral bodies does not occur because of the intact ‘ mechanical linkages ’. An unstable injury is one where further displacement can occur because of serious disruption of the structures responsible for stability. Recent biomechanic studies show that from the viewpoint of stability, the spine can be divided into three columns : Anterior, Middle Posterior.

11. BIOMECHANICS OF INJURY The anterior column consists of the anterior longitudinal ligament and the anterior part of annulus fibrosus along with the anterior half of the vertebral body. The middle column consists of the posterior longitudinal ligament and the posterior part of the annulus fibrosus along with the posterior half of the vertebral body. The posterior column consists of the posterior bony arches along with the posterior ligament complex.

12. BIOMECHANICS OF INJURY In different spinal injuries, the integrity of one or more of these columns may be disrupted, resulting in threat to the stability of the spine. When only one column is disrupted (e.g., a wedge compression fracture of the vertebra) the spine is stable. When two columns are disrupted (e.g., a burst fracture of the body of the vertebra) the spine is considered unstable. When all the three columns are disrupted, the spine is always unstable (e.g., dislocation of one vertebra over other).

13. 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

14. FLEXION INJURY This is the commonest spinal injury. Examples: ( i ) heavy blow across the shoulder by a heavy object (ii) fall from height on the heels or the buttocks.

15. FLEXION INJURY Results : In the cervical spine, a flexion force can result in: ( i ) a sprain of the ligaments and muscles of the back of the neck: (ii) compression fracture of the vertebral body, C5 to C7 ; and (iii) dislocation of one vertebra over another (commonest C5 over C6 ). In the dorso -lumbar spine, this force can result in the wedge compression of a vertebra (L1 commonest, followed by L2 and D12). It is a stable injury if compression of the vertebra is less than 50 per cent of its posterior height.

16. FLEXION-ROTATION INJURY This is the worst type of spinal injury because it leaves a highly unstable spine, and is associated with a high incidence of neurological damage. Examples: ( i ) heavy blow onto one shoulder causing the trunk to be in flexion and rotation to the opposite side (ii) a blow or fall on postero -lateral aspect of the head.

17. FLEXION-ROTATION INJURY Results: In the cervical spine this force can result in: ( i ) dislocation of the facet joints on one or both sides (ii) fracture-dislocation of the cervical vertebra. In the dorso -lumbar spine, this force can result in a fracture-dislocation of the spine. Here one vertebra is twisted off in front of the one below it. While dislocating, the upper vertebra takes a slice of the body of the lower vertebra with it. There is extensive damage to the neural arch and posterior ligament complex. It is a highly unstable injury.

18. VERTICAL COMPRESSION INJURY It is a common spinal injury. Examples: ( i ) a blow on the top of the head by some object falling on the head (ii) a fall from height in erect position.

19. VERTICAL COMPRESSION INJURY Results : In the cervical spine, this force results in a burst fracture i.e., the vertebral body is crushed throughout its vertical dimensions. A piece of bone or disc may get displaced into the spinal canal, causing pressure on the cord. In the dorso -lumbar spine, this force results in a fracture similar to that in the cervical spine, but due to a wide canal at this level, neurological deficit rarely occurs. It is an unstable injury.

20. EXTENSION INJURY This injury is commonly seen in the cervical spine. Examples: ( i ) motor vehicle accident – the forehead striking against the windscreen forcing the neck into hyperextension (ii) shallow water diving – the head hitting the ground, extending the neck. Results : This injury results in a chip fracture of the anterior rim of a vertebra. Sometimes, these injuries may be unstable.

21. FLEXION-DISTRACTION INJURY This is a recently described spinal injury, while driving a car. Example: With the sudden stopping of a car, the upper part of the body is forced forward by inertia, while the lower part is tied to the seat by the seat belt. The flexion force thus generated has a component of ‘distraction’ with it. Results: It commonly results in a horizontal fracture extending into the posterior elements and involving a part of the body. It is termed a ‘ Chance fracture ’. It is an unstable injury

22. FLEXION-DISTRACTION INJURY

23. DIRECT INJURY This is a rare type of spinal injury. Examples: ( i ) bullet injury; (ii) a lathi blow hitting the spinous processes of the cervical vertebrae. Results: Any part of the vertebra may be smashed by a bullet, but, a lathi blow generally causes a fracture of the spinous processes only.

24. VIOLENT MUSCLE CONTRACTION This is a rare injury. Example: Sudden violent contraction of the psoas. Results: It results in fractures of the transverse processes of multiple lumbar vertebrae. It may be associated with a huge retro-peritoneal hematoma.

25. CLINICAL FEATURES Presenting complaints : A patient with a spinal injury may present in the following ways: Pain in the back following a severe violence to the spine: The history is often so classic that one can predict the type of injury likely to have been sustained. At times the pain is slight, and one may not even suspect a spinal injury. Sometimes, a mild compression fracture of a vertebra may occur from a little jerk in the osteoporotic spine of an elderly person.

26. CLINICAL FEATURES Neurological deficit : Sometimes, a patient is brought to the hospital with complaints of inability to move the limbs and loss of sensation. Mostly there is a history of violence to the spine immediately preceding the onset of these complaints. Sometimes, the paralysis may ensue late, or may extend proximally due to traumatic intra-spinal haemorrhage .

27. EXAMINATION A patient with suspected spinal injury should be treated as if it were certain unless proved otherwise on further clinical examination and investigation. Utmost care is required during examination and moving such a patient. Examination consists of the following: General examination : A quick general examination should be carried out to evaluate any hypovolaemic shock and associated injuries to the head, chest or abdomen. Neurological examination : It is carried out before examining the spine per se. By doing so, it will be possible to find the expected segment of vertebral damage. The level of motor paralysis, loss of sensation and the absence of reflexes are a guide to the neurological level of injury. It is easy to calculate the expected vertebral level from the neurological level.

28. EXAMINATION Examination of the spine : In a patient with a suspected spinal injury, utmost care must be observed during examination of the spinal column. If such care is not observed, in an unstable spine, movement at the fracture site may cause damage to the spinal cord. The patient should be tilted by an assistant just enough to permit the surgeon’s hand to be introduced under the injured segment. One may be able to feel the prominence of one or more of the spinous processes, tenderness, crepitus or haematoma at the site of injury.

29. INVESTIGATIONS Good antero-posterior and lateral X-rays centering on the involved segment provide reasonable information about the injury. Sometimes, special imaging techniques are required e.g., CT scan, MRI etc. Plain X-rays: This is helpful in: ( i ) confirmation of diagnosis (ii) assessment of mechanism of injury (iii) assessment of the stability of the spine.

30. INVESTIGATIONS Following features may be noted on plain X-rays : • Change in the general alignment of the spine i.e., antero-posterior bending (kyphosis) or sideways bending (scoliosis). • Reduction in the height of a vertebra. • Antero-posterior or sideways displacement of one vertebra over another. • Fracture of a vertebral body. • Fracture of the posterior elements i.e., pedicle, lamina, transverse process etc.

31. INVESTIGATIONS Occasionally, plain X-rays may appear normal in the presence of a highly unstable spinal injury. This is commonly seen in ‘ whiplash ’ injury to the cervical spine where all the three columns of the spine are disrupted in a sudden hyperflexion followed by sudden hyperextension of the neck. e.g., after the sudden stopping of a car. Sometimes, a dislocation of the cervical spine may be spontaneously reduced so that there are only minimal findings on X-ray.

32. INVESTIGATIONS Following are some of the radiological features suggestive of an unstable injury: • Wedging of the body with the anterior height of the vertebra reduced more than half of the posterior height. • A fracture-dislocation on X-ray. • Rotational displacement of the spine. • Injury to the facet joints, pedicle or lamina. • An increase in the space between the adjacent spinous processes as seen on a lateral X-ray.

33. INVESTIGATIONS Tomogram : A tomogram helps in better delineation of a doubtful area. Myelogram has no role in the management of acute spinal injuries. MRI : It is the best modality of imaging an injured spine. In addition to showing better the details of injured bones and soft tissues, it shows very well the anatomy of the cord. CT scan : This can be done, where facility for MRI is not available. One can see the damaged structures more clearly, and make note of any bony fragments in the canal.

34. 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 department, or in the ward. Phase III - Rehabilitation.

35. TREATMENT PHASE I - EMERGENCY CARE : At the site of accident: An acute pain in the back following an injury is to be considered a spinal injury unless proved otherwise. Also, all suspected spinal injuries are to be considered unstable unless their stability is confirmed on subsequent investigation. Based on this, a patient with a spinal injury has to be given utmost care right at the site of accident; the basic principle being to avoid any movement at the injured segment. While moving a person with a suspected cervical spine injury, one person should hold the neck in traction by keeping the head pulled. The rest of the body is supported at the shoulder, pelvis and legs by three other people.

36. TREATMENT Whenever required, the whole body is to be moved in one piece so that no movement occurs at the spine. The same precaution is observed in a case with suspected dorso -lumbar injury. In the emergency department: The patient should not be moved from the trolley on which he is first received until stability of the spine is confirmed. In cases with cervical spine injury, two sand bags should be used on either side of the neck in order to avoid any movement of the neck. A quick general examination of the patient is carried out in order to detect any other associated injuries to the chest, abdomen, pelvis, limbs etc. A thorough neurological examination of the limbs is performed. The spine is examined for any tenderness, crepitus, haematoma etc. X-ray examination, as desired, is requisitioned.

37. TREATMENT Medical management of spinal cord injury: If the patient presents within 8 hours of injury, IV methylprednisolone is administered as a bolus dose followed by maintainence dose. Naloxone, thyrotropin-releasing hormone and GM1 gangliosides have been used . PHASE II - DEFINITIVE CARE : Definitive care of a patient with spinal injury depends upon the stability of the spine and the presence of a neurological deficit. The aim of treatment is: ( i ) to avoid any deterioration of the neurological status; (ii) to achieve stability of the spine by conservative or operative methods; and (iii) to rehabilitate the paralysed patient to the best possible extent .

38. TREATMENT Treatment of the various type of spinal injuries, as practiced most widely is as discussed below: Treatment of cervical spine injuries : Cervical spine injuries are often associated with head injury, the effect of which may mask the spinal lesion. Therefore, it is necessary to get an X-ray of the cervical spine in any serious case of head injury. Aim of treatment is to achieve proper alignment of vertebrae, and maintain it in that position till the vertebral column stabilises . Operative stabilization of the fractured spine has become the treatment of choice, as it enhances rehabilitation.

39. TREATMENT Where facilities are not available, reduction and stabilisation can be done by non-operative methods as discussed below : Reduction is achieved by skull traction applied through skull calipers – Crutchfield tongs . A weight of up to 10 kg is applied and check X-rays taken every 12 hours. Also a close watch is kept on the patient’s neurological status, because it is possible to damage the spinal cord or the medulla by injudicious traction.

40. TREATMENT When it is confirmed on X-rays that reduction has been achieved, light traction is continued for 6 weeks. This is followed by immobilisation of the neck in a moulded PoP cast or a plastic collar. In about 3-4 months, a bony bridge forms between the subluxed vertebrae, and the spine stabilises . The collar can then be discarded. Operation: This may be particularly required for: ( i ) irreducible subluxation because of ‘locking’ of the articular processes or (ii) persistent instability. The operation consists of inter-body fusion (anterior fusion) or fusion of the spinous processes and laminae (posterior fusion). Internal fixation may be required.

41. TREATMENT Common cervical spine injuries : Wedge compression fracture of the vertebral body: This results from a flexion force. The posterior elements are usually intact so that the injury is stable. Treatment: Reduction is not required. The neck is kept immobilised with the help of skull traction/ sling traction. Once pain and muscle spasm subside, the neck is supported in a cervical collar, PoP cast or a brace. Exercises of the neck are started after 8-12 weeks.

42. TREATMENT Burst fracture of the vertebral body : This results from a vertical compression force. The posterior elements are usually intact but because of the severity of crushing of the vertebra, fracture is considered unstable. It may be associated with a neurological deficit if a broken fragment from the body gets displaced inside the spinal canal. Treatment: Where there is no neurological deficit, the injury can be treated on the same lines as for wedge compression fractures mentioned above.

43. TREATMENT Subluxation or dislocation of the cervical spine : A flexion rotation force or a severe flexion force may result in the forward displacement of one vertebra over the other (commonly C5 over C6 ). The displacement may be partial or complete. Sometimes, the displacement may be spontaneously reduced, leaving a well aligned spine but significantly devoid of supporting ligament; these are unstable injuries. For proper assessment, in addition to antero-posterior and lateral views, oblique X-ray views may be taken. MRI gives critical information about extent of injury. Treatment: Surgical stabilisation is the treatment of choice. Some cases can be treated conservatively. The aim of treatment is to achieve reduction of the subluxed vertebra and maintain it in a reduced position until the spine becomes stable.

44. TREATMENT Uncommon cervical spine injuries : Fracture of the atlas: A ‘burst’ fracture where both, anterior and posterior arches of the atlas, are fractured by a vertical force acting through the skull is a common atlas fracture ( Jefferson’s fracture ). Displacement is seldom severe, and more often than not, the spinal cord escapes injury. Treatment consists of traction, followed by immobilisation in Minerva jacket or halopelvic support.

45. TREATMENT Atlanto -axial fracture-dislocation : A fracture dislocation of the atlanto -axial joint is more common than pure dislocation. A pure dislocation is more often associated with a neurological deficit. The displacement is commonly anterior. Treatment consists of skull traction, followed by immobilisation in a Minerva jacket. In due course, the fracture unites and a bridge of bone joins C1 to C2 anteriorly, thereby stabilising the spine.

46. TREATMENT Clay shoveller’s fracture : This is a fracture of the spinous process of D1 vertebra. It is caused by muscular action as occurs in shovelling by labourers , hence its name. Displacement of intervertebral disc: A violent flexion-compression force can sometimes result in sudden prolapse of the nucleus pulposus of a cervical disc into the vertebral canal resulting in quadriplegia. An early decompression may give good results.

47. TREATMENT Treatment of thoracic and lumbar spine injuries : Stable injuries : Most of these need a period of bed rest and analgesics followed by mobilisation . During the period of bed rest, one must take special care of possible complications such as bed sores, chest infection, urinary tract infection etc. Unstable injuries : These are either associated with a neurological deficit or are likely to develop it during treatment. Open reduction and surgical stabilisation gives the best choice of recovery but conventionally, these cases have been treated non-operatively with: ( i ) bed rest for 6 weeks; (ii) bracing till spine stabilises ; and (iii) care of the back.

48. TREATMENT Operative intervention : This is particularly required under the following circumstances: a) Partial neurological deficit with CT or MRI proven compromise of the spinal canal. b) Worsening of the neurological deficit. c) Multiple injured patient

49. TREATMENT Operative methods : Whenever necessary the following operative methods are performed : • Harrington instrumentation – bilateral • Luque instrumentation • Hartshill rectangle fixation • Pedicle screw fixation • Moss Miami system

50. SPINAL CORD INJURIES Dr. M SANTOSH BABU ASSISTANT PROFESSOR

51. TRAUMATIC PARAPLEGIA Only a small proportion of cases of spinal injuries are complicated by injury to the neural structures within the vertebral column. In the cervical spine, it may lead to paralysis of all four limbs ( quadriplegia ). In thoracic and thoraco-lumbar spine, it may result in paralysis of the trunk and both lower limbs ( paraplegia ). The terms quadriparesis and paraparesis are sometimes used for incomplete paralysis of all four limbs or the lower limbs respectively.

52. TRAUMATIC PARAPLEGIA The commonest spinal injury to be associated with paraplegia is a fracture-dislocation (flexion-rotation injury) of the dorso -lumbar spine. Quadriplegia most commonly results from fracture-dislocation (flexion-rotation injuries) at the C5 -C6 junction. Only severely displaced lumbar spine injuries below L1 level, produce cauda equina type of paralysis.

53. PATHOLOGY The displaced vertebra may either damage the cord (very unlikely), the cord along with the nerve roots lying by its side or the roots alone. Pathologically, damage to neural structures may be a cord concussion, cord transection or root transection

54. CORD CONCUSSION In this type, the disturbance is one of functional loss without a demonstrable anatomical lesion. Motor paralysis (flaccid), sensory loss and visceral paralysis occur below the level of the affected cord segment. Recovery begins within 8 hours, and eventually the patient recovers fully.

55. CORD TRANSECTION In this type, the cord and its surrounding tissues are transected. The injury is anatomical and irreparable. Initially, the motor paralysis is flaccid because the cord below the level of injury is in a state of ‘spinal shock’. After some time, however, the cord recovers from shock and acts as an independent structure, without any control from the higher centres . In this state, though the cord manifests reflex activity at spinal level, there is no voluntary control over body parts below the level of injury. There is total loss of sensation and autonomic functions below the level of injury

56. CORD TRANSECTION The appearance of signs suggestive of reflex cord activity i.e., bulbo-cavernosus reflex, anal reflex and plantar reflex, without recovery of motor power or sensations is an indicator of cord transection. These reflexes usually appear within 24 hours of the injury. In a few days or weeks, the flaccid paralysis (due to spinal shock) becomes spastic, with exaggerated tendon reflexes and clonus. Involuntary flexor spasms at different joints and spasticity leads to contractures. Sensation and autonomic functions never return.

57. ROOT TRANSECTION Spinal nerve roots may be damaged alone in injuries of the lumbar spine, or in addition to cord injury, in injuries of the dorso -lumbar spine. Neurological damage in nerve root injury is similar to that in cord transection except that in the former residual motor paralysis remains permanently flaccid and regeneration is theoretically* possible. A discrepancy between the neurological and skeletal levels may occur in spinal injuries below D10 level because the roots descending from the segments higher than the affected cord level may also be transected, thereby producing a higher neurological level than expected.

58. INCOMPLETE LESIONS Occasionally, the neurological lesion may be incomplete i.e., affecting only a portion of the cord. In these cases, there is evidence of neurological sparing distal to the injury (perianal sensation sparing is common). Such sparing is an indication of a favorable prognosis.

59. INCOMPLETE LESIONS Incomplete lesions may be of the following types: a) Central cord lesion : This is the commonest incomplete lesion. There is initial flaccid weakness followed by a lower motor neurone type of paralysis of the upper limbs and upper motor neurone (spastic) paralysis of the lower limbs, with preservation of bladder control and perianal sensations (sacral sparing). b) Anterior cord lesion : There is complete paralysis and anaesthesia but deep pressure and position sense are retained in the lower limbs (dorsal column sparing). c) Posterior cord lesion : It is a very rare lesion. Only deep pressure and proprioception are lost. d) Cord hemi-section ( Brown-Sequard syndrome ): There is ipsilateral paralysis and contralateral loss of pain sensation

60. NEUROLOGICAL DEFICIT AND SPINAL INJURIES Cervical spine : In these injuries, the segmental level of the cord transection nearly always corresponds to the level of bony damage. A high cervical cord transection (above C5 ) is fatal because all the respiratory muscles (thoracic and diaphragmatic) are paralysed . Transection at the C5 segment results in paralysis of the muscles of the upper limbs, thorax, trunk, and lower limbs, with loss of sensation and visceral functions. With transection at level below the C5 segment, some muscles of the upper limbs are spared, resulting in characteristic deformities, depending upon the level.

61. NEUROLOGICAL DEFICIT AND SPINAL INJURIES Thoracic lesion (betweenT1 and T10): In cord transection from T1 to T10, trunk and lower limb muscles are paralysed . At the tenth thoracic vertebra, the corresponding cord segment is L1 , so in injuries at this level, only the lower limbs are affected.

62. NEUROLOGICAL DEFICIT AND SPINAL INJURIES Dorso -lumbar lesions (between D11 and L1 ): Between 11th dorsal and 1st lumbar vertebrae lie all the lumbar and sacral segments along with their nerve roots. Hence, injuries at this level cause cord transection with or without involvement of nerve roots. This is the cause of difference in neurological deficit in fractures and fracture-dislocations with apparently similar X-ray appearances. In injuries of the cord with nerve root transection, paralysis in the lower limbs is mixed (UMN+LMN type).

63. NEUROLOGICAL DEFICIT AND SPINAL INJURIES Lesions below L1 : This area of the canal has only bunch of nerve roots, which subsequently emerge at successive levels of the lumbo-sacral spine. Thus, injury in this area results in root damage, resulting in flaccid paralysis, sensory loss and autonomic disturbances in the distribution of the affected roots.

64. CLINICAL EXAMINATION A neurological deficit following trauma to the spine is difficult to miss. More important is to perform a thorough neurological examination to evaluate the following: ( i ) the level of neurological deficit; (ii) any evidence of an incomplete lesion; and (iii) any indication of complete cord transection

65. INVESTIGATIONS Radiologicalexamination : Often there is no correlation between the severity of the injury on the X-rays and the degree of neurological deficit. CT and MRI scan : This may be indicated in cases with incomplete paralysis, particularly if it is increasing. It is also indicated in cases where no bony lesions are visible on plain X-rays. MRI has become the imaging modality of choice for these cases

66. TREATMENT Treatment can be discussed in 3 phases: Phase I Emergency care at the scene of accident and in the emergency department Phase II Definitive care on in-patient basis Phase III Rehabilitation

67. TREATMENT PHASE I – EMERGENCY CARE The care in phase I is along the lines already discussed in ‘treatment of spinal injuries’. PHASE II – DEFINITIVE CARE Care in phase II consists of: ( i ) clinical assessment of the neurological deficit; (ii) radiological and special investigations to understand the type of vertebral lesion, and to detect the possibility of persistent cord compression by a bone fragment in the vertebral canal; and (iii) care of paraplegic in the ward.

68. TREATMENT Ward care of a paraplegic : Ward care of a traumatic paraplegic or quadriplegic consists of: ‘ ( i ) management of the fracture; (ii) nursing care; (iii) care of the bladder and bowel; and (iv) physiotherapy

69. TREATMENT Management of the fracture : Treatment of the fracture or fracture-dislocation per se is the same as that for spinal injury at that level without neurological lesion. It consists of stabilisation of the spine by internally fixing it. This ensures better nursing care of the patient but offers no security about the recovery of neurological function. The generally accepted indications for surgery can be considered as follows: a) Incomplete paralysis, particularly if it is increasing, and a CT scan shows fragments of bone encroaching upon the spinal canal. b) Patient with multiple injuries, in whom it is desirable to stabilise the spine for overall optimum care of the patient

70. TREATMENT Nursing care: a) Positioning in bed b) Care of the back c) Personal hygiene d ) Care of the bowel Physiotherapy

71. TREATMENT PHASE III – REHABILITATION ( i ) physical rehabilitation; (ii) psychological and social rehabilitation; and (iii) economic rehabilitation. Physical rehabilitation

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