SPiNAL INJURY AND IT'S CURRENT MANAGEMENT : CME -

SPiNAL INJURY AND IT'S CURRENT MANAGEMENT : CME -

1. CME ON
Spinal Injury
And It’s Management
1
Prepared by -
Dr. MdNazrul Islam, MBBS, M.sc.
Supervised by -
Dr. Sk. AbbasUddinAhmed
MS(Ortho),AO(Basic),AO(Spine).
Presenting by -
Dr. Abdul Hannan
From-
DepartmentOfOrthopaedic&Traumatology,
ShaheedSuhrawardyMedicalCollegeHospital.Dhaka.

2. Spinal Injury & its Management

3. Over view
Spinal Injury & its Management
Definition of spinal injury
Anatomy of human spine
Classification of spinal injury
Epidemiology
Pathophysiologyof spinal injury
Clinical features of spinal injury
Investigations
Diagnosis
Management
Prognosis
Rehabilitations
Conclusions
Functions of spine

4. The spine has many functions, the main ones
are listed below-
1.To provide protection of the spinal cord
and associated nerves
2.To allow for movement
3.To support our body frame in an upright
position
4. To allow for flexibility
5. To provide a structural foundation for the
shoulder girdle and the pelvic girdles
6. To act as shock absorbers from load-
bearing
7. To provide a structural base for rib
attachments which protect the heart and
lungs.
Spinal Injury & its Management

5. “ Spinalinjury” may be defined
as-
Injury to the Spinal column (Bony
Column)/Spinal Cord,
or both of them.
Spinal injury can be divided into-
Spinal Column(Bony)Injury.
Spinal Cord injury.
Combined (Both Column &
Cord) Injury.
Definition Of Spinal
Injury:
Spinal Injury & its Management
Spinal Injuries

6. Spinal Column
Injury
Bony spinal injuries may or may not
be associated with spinal cord injury
These bony injuries include:
Compression fractures of the
vertebrae
Comminuted fractures of the
vertebrae
Subluxation(partial dislocation) of
the vertebrae
Other injuries may include:
Sprains-over-stretching or tearing of
ligaments
Strains-over-stretching or tearing of
the muscles.
Spinal Injury & its Management

7. Spinal Cord Injury
Cutting, compression, or stretching
of the spinal cord
Causing loss of distal function,
sensation, or motion
Caused by:
Unstable or sharp bony fragments
pushing on the cord, or
Pressure from bone fragments or
swelling that interrupts the blood
supply to the cord causing
ischemia.
7
Spinal Injury & its Management

8. 9
Risk factors:
Alcohol intoxication
Drug abuse
Participation in high-
risk activities:
Diving
Contact sports
Osteoporosis
Epidemiology
Spinal Injury & its Management
50% of SCI’s are complete
50-60% of SCI’s are cervical
Immediate mortality for complete cervical
SCI ~ 50%
Occurs primarily in young males (> 75%
of cases)
Half of these injuries result from MVAs
2/3 of patients are < 30 years old
Other sources of SCI: Falls, sporting
and industrial accidents, gunshot wounds.
Most common vertebrae involved are
C5, C6, C7, T12, and L1 because they
have the greatest ROM.

9. 10 -15 per million
18 -35 years
Male -3:1
RTA 51% -cars
Domestic 16%
Industrial 11%
Sports 16% -diving incidents
Self harm 5%
Epidemiology
Incidence
Spinal Injury & its Management

10. Cervical 40%
Thoracic 10%
Lumbar 3%
Dorsolumbar 35%
Any 14%
Types of Spinal Injury-
Spinal Injury & its Management

11. 11
Spinal Injury & its Management
Incompleteinjury:
Somemotororsensoryfunctionsisspared
distaltothecordinjury.Voluntarysphincter
contraction,toeflexorcontraction–present.
Prognosis-Good’
Completeinjury:
Totalmotor&sensorylossdistaltotheinjury
afterSpinalshock(usuallylastsfor24-48
hrs)isover.Whenthebulbocavernosus
reflexispositive&nosacralsensationor
motorfunctionhasreturned,paralysiswill
bepermanent&completeinmostpatients.

12. PATTERNS OF MULTIPLE SPINAL
INJURY :
Pattern:A.Primarylesionoccurbetween
C5&C7withsecondaryinjuriesat
T12orthelumberspine.
Pattern:B.PrimaryinjuryatT2-T4with
secondaryinjuryincervicalspine.
Pattern:C..Primaryinjuryoccur
betweenT12&L2withsecondary
injuriesfromL4-L5.

13. Acute:
Causedbyboneorligament
disruptionthatplacesthenormal
elementsindangerofinjurywithany
subsequentloadingdeformity.
Chronic:
Resultofprogressivedeformitythat
maycauseneurologicaldeterioration.
CLINICAL INSTABILITY

14. 14
Degenerative Disease Of Spine
Spinal Canal Stenosis
AnkylosingSpondylitis
Down's Syndrome
Klippel-feilSyndrome
Arnold-chiariMalformation
Metastatic CA
Osteomyelitis
Rheumatoid Arthritis.
Predisposing factors
Spinal Injury & its Management

15. Spinal Injury & its Management
Spine consists of alternating
Bony vertebrae
Fibrocartilaginousdisc
Supported by musculature.
Motion segment –Two adjacent
vertebrae with intervening disc.

16. Spinal Injury & its Management
Anatomy of the spine is usually
described by dividing up the spine
(Bony vertebrae) into 3 major bony
sections:
Thecervical,
Thethoracic, and
Thelumbarspine in which the spinal
cord is embedded.
(Below the lumbar spine is a bone
called thesacrum, which is part of
the pelvis).
Each section is made up of individual
bones calledvertebrae. There are 7
cervical vertebrae, 12 thoracic
vertebrae, and 5 lumbar vertebrae.

17. 5
Spinal Injury & its Management
•Anterior column = anterior 2/3 of
the vertebral body, disc, and annulus,
and the anterior longitudinal ligament)
•Middle column = posterior 1/3 of
the vertebral body, disc, annulus, and
the posterior longitudinal ligament
•Posterior column = pedicles, laminae,
facets, capsule, and the interspinous
and supraspinousligament.
injury is said to be stable if only one
of the columns is involved.
damage to two or more columns or
risking neurological injury (iedamage
to the middle column) -unstable.
Stability of Spine-

18. 8
Primary mechanism of cord injury can
be due to four kinds of mechanical
forces.
a. Impact with persisting compression e.
g. fractures, dislocations, and disc
herniations.
b. Impact with no persisting compression
e. g. hyperextersioninjuries.
c. Distraction e. g. hyperflexioninjuries.
d. Laceration/ Transection: Penetrating
injuries, fracture dislocation.
Spinal Injury & its Management
Most likely to occur at sites of
maximum mobility
•Adults C6
•Children <8 yrs old C2.

19. Pathophysiologyof spinal
cord injury:
Spinal Injury & its Management
Secondary injury mechanisms that may be
involved are:
a. Systemic shock: Profound hypotension, and
bradycardia(often lasting for days) follows
cord injury and there may be a compromise of
an already damaged cord.
b. Local microcirculatory damage: may be due
to mechanical disruption of capillaries,
hemorrhage, thrombosis and loss of
autoregulation.
c. Biochemical damage: may occur due to
excitotoxinrelease (glutamate), free radical
production, arachidonicacid release, lipid
peroxidation, eicosanoidproduction, cytokines
and electrolyte shifts.

20. 25% of spinal cord injuries occur after primary
injury.
Primary injury results from focal injuries (eg
avulsion, contusion, laceration and intra-
parenchymalhemorrhage) and diffuse lesions
(e.g. concussive and diffuse axonal injury).
Further mechanical disruption can result from
external compression or angulationand
ischemic damage from occlusion of arterial
supply.
Primary injury
Spinal Injury & its Management

21. Secondary injury
Immediately after an acute spinal cord
injury major reduction in blood flow occurs
at the level of the lesion. Becomes
progressively worse over the first few hours
if left untreated. Pathophysiology
underlying this ischaemiais unclear but
involves both systemic and local effects.
Putative local mechanisms include
vasospasm, endothelial swelling or damage,
haemorrhagecausing obstruction of small
blood vessels, loss of autoregulationand
impaired venous drainage.
21
Results from:
•Cellular hypoxia
•Oligaemia
Spinal Injury & its Management

22. 22
Secondary injury-
Spinal Injury & its Management
Secondary Injury Cascade
Current understanding

23. Primary Neurological damage
Direct trauma, haematoma&
SCIWORA < 8yrs old
In 4hrs -Infarction of white matter
occurs
In 8hrs -Infarction of grey matter
and irreversible paralysis
Secondary damage
Hypoxia
Hypoperfusion
Neurogenicshock
Spinal shock
Spinal Injury & its Management

24. Factors affecting the severity of
a spinal lesion-
Loss of neural tissue -obvious
Vertical level –Higher up, the
greater the damage
Transverse plane –What Diameter
has a lesion
Spinal Injury & its Management

25. Spinal Injury & its Management
Pain
Breathing difficulty
Sensitivity to stimuli
Muscle spasms
Loss of sensation
Loss of reflex function
Loss of autonomic activity
Loss of bowel control
Loss of bladder control
Sexual dysfunction
Loss of function, such as mobility or sensation
Paralysis
Common features of spinal
injuries are-

26. “Level" of cord lesion is conventionally the
most caudal location with normal motor and
sensory function.
Motor level = the last level with at least 3/5
(against gravity) function
NB: this is the most important for
clinical purposes
Sensory level = the last level with preserved
sensation
Radiographic level = the level of fracture on
plain XRays/ CT scan / MRI
NB: spine level does not correspond to
spinal cord level below the cervical
region.
Spinal Injury & its Management

27. Spinal shock may mimic a complete cord
lesion with total loss of motor and sensory
function distal to injury. However if lesion is
incomplete some function will return
99% of patients with a complete lesion over
24 h will not show functional recovery
Patients with partial lesion may regain
substantial or even normal neurological function
even though the initial neurological deficit may
be severe
Presence of bulbocavernousreflex or anal-
cutaneousreflex indicates sacral sparing and a
more favorable prognosis.
Spinal Injury & its Management

28. Spinal Injury & its Management
A. Clinical laboratory tests.
Laboratory testswill be guided by
clinical assessment of patient (history
and physical examination).
In addition to routine investigations
diagnostic imaging is very important.
B. Diagnostic imaging.
1.X-RAY
2.CT SCAN
3.MRI

29. Spinal Injury & its Management
Indications for screening radiology. History of
trauma and:
Not fully conscious
Drowsy or intoxicated
Focal neurological deficit
Midline cervical tenderness
Other painful injury that may mask neck pain,
particularly fractures
Screening radiology of choice is CT of spine.
Additional indications are-
oExtremes of age
oMechanism of injury highly suggestive of
cervical spine injury
oSignificant facial trauma
Sensitivity approximately 98% and considerably
higher than plain radiography.May miss soft tissue
injury and spinal cord injury in the absence of bony
injury.

30. Although CT may miss soft tissue and
spinal cord injury, MRI is a sensitive
alternative method.
Almost never an emergency
Exception: caudaequina
syndrome
Shows tumors and soft tissues (e.g.,
herniated discs) much better than CT
scan.
RiskoftransfertoMRIabilityofMRIto
detectsofttissueinjurymayfallafter
72hour.
25
Spinal Injury & its Management

31. 25
Spinal Injury & its Management
The term SCIWORA (spinal cord injury without
radiologic abnormality) originally referred to
spinal cord injury without radiographic or CT
evidence of fracture or dislocation.
However with the advent of MRI, the term has
become ambiguous. Findings on MRI such as
intervertebraldisk rupture, spinal epidural
hematoma, cord contusion, and hematomyelia
have all been recognized as causing primary or
secondary spinal cord injury.
SCIWORAshould now be more correctly
renamed as "spinal cord injury without neuro-
imaging abnormality" and recognize that its
prognosis is actually better than patients with
spinal cord injury and radiologic evidence of
traumatic injury.
SCIWORA
(spinal cord injury without
radiologic abnormality)
Incidence 3-5% (x-ray/CT)
Higher incidence in paediatric
population (34.8%)-
The relatively large size of the
head. inherent skeletal mobility.
cord vulnerable to damage.
Higher incidence above 60 yo-
Posteriorvertebralspursdueto
spondylosis.Ligamentumflavum
bulgingduetolossofdischeight.
Riskofcentralcordsyndromeafter
hyperextensioninjury.

32. 20
History-
1. Mechanism of injury
2. Misdiagnosis -head injury, acute
alcoholic intoxication and multiple
injuries.
3.Decreasedlevelofconsciousness
orcomatosepatientsmaynot
complainofneckpain.
4. Profuse bleeding from face and
scalp may divert attention from
cervical spine injury

33. 21
General examination:
a)Headandear
b)Spinousprocessandinterspinous
ligamentspalpation
c)Elbowsmaybeflexedifaspinalcord
injurycauseslossoffunctionbelowbiceps
andmaybeextendediftheparalysisis
higher.
d)Penileerectionandincontinenceofthe
bowelandbladder-significantspinal
injury.
e)Flaccidparalysisoftheextremities–
Quadriplegia
f)Chestabdomenandextremities–Other
injuries.

34. 22
Accurate and detailed neurological
evaluation –very important
Level of consciousness-Pupillarysize and
reaction, epidural or subdural haematoma,
depressed skull fracture.
Evaluation of sensory (pinprick), motor and
reflex function.
Importantdermatomelandmarksare-
•Nippleline–T4
•Xiphoidprocess-T7
•Umbilicus–T10
•Inguinalregion–T12,L1
•Perineumandperi-analregion(S2,S3&S4)

35. 35
Pre-Hospital
Management.
Hospital
Management.

36. Primary(Pre-hospital)
management-
36
Initial treatment of patients with cord injury
focuses on two aspects -preventing further
damage and resuscitation.
Immobilization with a hard cervical collar (in case of
cervical spine injuries) and care in transportation of
patient is of paramount importance if the spine is
unstable.
Resuscitationis aimed at airway
maintenance, adequate oxygen saturation of
peripheral blood, restoring blood pressure
to acceptable limits, preventing
bradycardia, done simultaneously to prevent
any ischemic damage to the already
compromised cord.

37. Secondary (Hospital)
Management:
Medical Management
Conservative (General)-
Conservative (Medical)-
Surgical Management
Surgical Decompression
Surgical Stabilization
Fixation of Vertebra
Fixation of Spine
Artificial disc implantation
Spinal Injury & its Management

38. 32
Conservative(General)-
Spinal Injury & its Management
.
Resuscitation according to ATLS
guidelines
Determination of neurological injury
Prevention of neurological deterioration
Ongoing ID & Txof assoc injuries
Prevention of complications
Initiation of definitive management for
vertebral column injury or SCI
Immediate Management-
Goals:

39. Aimistopreventextensionofprimary
injury,toreducesecondaryinjuryandto
treatcomplications-
Follow ATLS principles-
32
Conservative(General)-
Spinal Injury & its Management
Airway; protect Spine
Breathing
Circulation
Disability, Dxand Rx shock
Exposepatient
And
Treat Secondary survey.

40. 40
Conservative(Medical)-
Conservativetreatmentsofspinaldisorders
haveimprovedsignificantlyovertheyears.
Ofthemanyconservativenon-surgical
treatmentsthatarecurrentlyavailable,afew
ofthemostcommonlypracticedtreatments
are-
•Epidural Steroid Injection
•Intradiscalthermoplasty(IDET)
•Nucleoplasty
•Facet Injections, and/orMedial Branch
Blockade
•Radio Frequency RhizotomyorDenervation.
Spinal Injury & its Management

41. Dependingonthecircumstances,whensurgeryis
required.
Surgerymaybeconsideredifthespinalcordis
compressedandwhenthespinerequires
stabilization.
Thesurgeondecidestheprocedurethatwill
providethegreatestbenefitforthepatient.
Thecommonprocedureswhichweperformare-
Surgical Decompression
Surgical Stabilization
oSpinal fusion
oFixation of Vertebra
oFixation of Spine
Discectomy, foramenotomyand
laminectomy(Some times needed).
Artificial disc implantation. 41
Spinal Injury & its Management
Surgical-

42. Surgical Decompression and/
or Fusion-
Indications
oDecompression of the neural elements
(spinal cord/nerves)
oStabilization of the bony elements (spine)
Timing
oEmergent
Incomplete lesions with progressive
neurologic deficit
oElective
Complete lesions (3-7 days post injury)
Central cord syndrome (2-3 weeks post
injury).

43. 43
Spinal Injury & its Management
Surgical-

44. 33
Surgical-
Spinal Injury & its Management

45. 33
Spinal Injury & its Management
Surgical–
Spinalfixationimplants:

46. Spinal Injury & its Management
Skin Breakdown
Osteoporosis and Fractures:
Pneumonia, Atelectasis, Aspiration:
HeterotopicOssification:
Spasticity:
Autonomic dysreflexia:
Deep vein thrombosis:
Cardiovascular disease:
Syringomyelia-
Neuropathic/Spinal Cord Pain-
Respiratory Dysfunction-
Miscellaneous
pressure sores, Greatly increase cost and morbidity
Pokilothermiain patients with lesion above T1
hyponatraemiacommon in first week.
There are many complications of spinal Injury,
the followings are most common-

47. Rehabilitation afterspinal injury(SI) focuses
on the patient learning how to live life when
faced with physical, occupational, and
emotional challenges.
After SI, everything can change, and you
can face many issues including mobility,
regular exercise and maintaining a level of
fitness, communication challenges, and
activities of daily living.
Rehabilitation may be accomplished at a
hospital, outpatient clinic, home, or a
combination.
Spinal Injury & its Management

48. 36
Accreditedrehabilitationcenters
provideSCIpatientswithateamof
professionalsandmanyresources.Some
oftheprofessionalsinclude:
oOccupational Therapist
oPhysiatrist.
oPhysical Therapist:
oRehabilitation Nurse.
oSpeech and Language Pathologist.
oTherapeutic Recreational Specialist.
oVocational Rehabilitation Therapist.
oRehab Psychologist
Spinal Injury & its Management

49. 39
Spinal Injury & its Management

50. 50
Prognosis
The main determinant of outcome is the patient's neurological
grade at the time of admission with patients having complete motor
and sensory myelopathyshowing the worst prognosis.
Other predictive factors include rectal tone status, admission blood
pressure and pulse status, reflexes, and medical and surgical
management since injury.
The time course of recovery is also prolonged and recovery itself
often incomplete.
Taking all grades and locations into considerations a study concluded
that while the majority of cases improved within a year, even at 3
years post injury 23.3% continue to improve whereas 7.1%
deteriorated. The trend continued in the 5th year post injury also with
12.5% and 5.5% respectively showing further improvement and late
deterioration. Hence prolonged rehabilitation at a comprehensive
spinal rehabilitation center is the management of spinal cord injuries.
Spinal Injury & its Management

51. 40
“Neurological disorders are the most
complicated problems known to medical
science today, and we require the best
scientific minds and technology in order to
find cures.”
W. Dalton Dietrich, Ph.D., scientific director,
The Miami Project to Cure Paralysis
Spinal Injury & its Management

52. Pre-hospital& hospital both phases are equally
important for SI management.
Surgical intervention improves recovery period, quality of
life and Rehab, reduces morbidity/ mortality .
SIis neglected and poorly managed. Research is sparse
and data is missing. The demographics, epidemiological
pattern ofSC in the developing world is different from the
developed world and this should be considered while
formulating polices for theSIin future.
Trauma evacuation protocols need to be developed and
pre hospital care of suspectedSIpatient should be
improved.
Regional and national spinal injury centers providing
comprehensive treatment and multidisciplinary rehabilitation
should be established.
Spinal Injury & its Management

53. From-
Department Of Orthopedics’ & Traumatology
ShaheedSuhrawardyMedical College Hospital.
Spinal Injury & its Management

54. 3/26/2011
54
Associate Prof. Dr. P. C. Debenath
Associate Prof. Dr. Sheikh AbbasUddin.
Associate Prof. Dr. ZiaulHaq
Associate Prof. Dr. ShamimulHaq
Associate Prof. Dr. MonowarulIslam
Associate Surgeon Dr. Md. AminurRahman
Assistant Prof. Dr. KaziShamimuzzaman
Assistant Prof. Dr. A T M BaharUddin
Dr. Abdul Hannan
And
Dr. MdNazrulIslam
Resident Surgeon,
Department of Orthopedic & Traumatology.
ShaheedSuhrawardyMedical College Hospital.
Spinal Injury & its Management