SPINAL TRAUMA ITS ANATOMY AND EMERGENCY MANAGEMENT OF

This PPT help to understand anatomy of spinal vertebra , spinal cord tracts
Dermatomes, myotomes, all types of vertibral and spinal fractures they assessment and initial management in emergency department

1. Spinal Trauma Dr KOSARAJU REVATI MD PEDIATRICS DR DRAVID M C MD EMERGENCY MEDICINE

2. Anatomy of Spine and vertibrae

3. Functional spinal unit

4. Quick review of Spinal tracts

5. Dermatomes

6. myotomes

7. INTRODUCTION AND EPIDEMIOLOGY Trauma to the spine can cause a vertebral column injury, a spinal cord injury, or both Due to its inherent flexibility, the cervical spine is overall the most commonly injured region of the spinal column, with most injuries occurring at the C2 level and from C5 to C7. The second most common region of injury is in the thoracolumbar transition zone (T11 to L2) Since 2010, the leading causes of spinal cord injury are vehicular (38%), falls (31%), and violence (13%) 55% in cervical region (mobile and Exposed) ,15% in thoracic region ( less mobile & protected ),15% in thoracolumbar region (fulcrum),15% in lumbosacral region

8. ETIOLOGY OF SPINAL TRUMA High Energy Trauma Fall from height Sports accident violent act, such as a gunshot wound osteoporosis Tumors other underlying conditions that weaken bone

9. Denis 3 column consept of spinal stability The Spinal cord can be divided into three columns Anterior, middle and posterior. spinal stability is dependent on atleast two intact columns when two of the three columns are disrupted, it will allow abnormal segmental motion, ie.instability Failure of two or more columns generally results in instability

10. Denis classification of Spinal Trauma. Major injuries COMPRESSION BURST SEAT-BELT-TYPE FRACTURE-DISLOCATION Minor injuries Transverse processes # Articular process# Para interarticularis # spinous process #

11. Major Spinal Column Injuries Mechanism of Injury- Flexion Injury- Anterior subluxation(hyperflexion sprain), usually stable, but Depends on the integrity of posterior ligaments) Regions Typically Affected- Cervical Anterior subluxation produces ligamentous failure and may have no associated fractures.Plain films can be normal. However, significant ligamentous injury can display anterior soft tissue swelling,a widening of the spinous processes at the level of injury(“fanning”),posterior widening of the inter vertebral space,and cervical diskspace alignment ≥11 degrees between adjacent spaces. .

12. Anterior subluxation

13. Atlantoaxial dislocation(unstable) Transverse ligament rupture without an associated fracturecan occur in older patients from a direct blow to the occiput. Radiographicdiagnosis- relieson measuring the predental space, which is the space between the posterior aspect of the anterior arch of C1 and the anterior borderof the odontoid. A predental spaceof >3 mm on a lateral radiograph (2 mm for CTimages) implies damageto the transverse ligament; >5 mm implies rupture of the transverse ligament.

14. Bilateral inter facetal dislocation (unstable) Bilateral interfacetal dislocation (locked facets) occurs when the articular masses of one vertebra dislocate anteriorly and superiorly from the articular surfaces of the adjacent vertebra below. Disruption of all ligamentous structures occurs. On radiographs , the vertebral body is dislocated anteriorly ≥50% of its width. These injuries usually present with neurologic deficits due to compromise of the intervertebral foramen,unless the dislocation is only partial (perched facets).

15. Simple wedge(compression) fracture(usually stable) Regions Typically Affected - Cervical;TL Most common thoracic fracture(52%). A vertebral wedge fracture typically involves a fracture of the superior end plate of the vertebral body while sparing the inferior end plate. An isolated simple wedge fracture is stable,but the presence of significant posterior ligamentous disruption can make the injury unstable. A simple wedge fracture is differentiated from aburst fracture by the absence of a vertical fractureof the vertebral body and lack of bulging of the posterior vertebral border.

16. Spinous process avulsion fracture(stable) This is a spinous process avulsion most commonly seen in the lower cervical and upper thoracic spine. When a single avulsion is present in this region, it is often called a “clay-shoveler” fracture. It is thought to be caused by strong muscle contractions pulling on the bone via the ligamentous complex. In isolation, it is generally not associated with neurologic compromise.

17. Flexion teardropfracture (highlyunstable) Extreme hyperflexion causes complete disruption of the spinal ligaments at the level of injury. The“teardrop” is the anteroinferior portion of the vertebral body that is separated and displaced from the vertebral body by the anterior spinal ligament. “Fanning” if the spinous processes may be present, with or without fracture. A sagittal fracture through the vertebral body may be seen on CT. Anterior spinal cord syndrome is associated with this injury

18. Flexion rotation Unilateral facet dislocation (stable unless associated with an articular mass fracture) Fractureof lateral mass (can be unstable )

19. Flexion distraction Anterior compression with associated transverse fracture through vertebral body (unstable) These injuries are associated with seat belt injuries Radiographic findings include posterior vertebral wall fracture, increased height of the posterior vertebra, and“fanning”of the spinous processes. It often occurs from T11 to L2(TL transition zone).

20. Vertical compression Jefferson burst fracture of atlas ( potentially unstable ) Burst fracture(unstable) - Cervical;TL

21. Extension Hyperextension dislocation (unstable) Extreme hyperextension can cause a complete tear of the anterior longitudinal ligament and intervertebral disk, with disruption of the posterior ligamentous complex. lateral radiographic view The vertebrae may appear normal if the dislocation spontaneously reducesor if the injury is masked by a cervical immobilization collar. Prevertebral soft tissue swelling may be the only radiographic finding present.

22. Hyperextension tear drop fracture or extension corner avulsion fracture (unstablein extension) Fracture of posteriorarch it of atlas (stable)

23. Traumatic spondylolisthesis (hangman’s fracture) (unstable) The hangman’s fracture is a fracture of both pedicles of C2, with the anterior displacement of C2 on C3. This was associated with the neck hyperextension from judicial hangings, where the noose knot is placed under the subject’s chin and snaps the head backward. Suicidal hangings do not usually cause extreme hyperextension and are not associated with the hangman’s fracture. Because the spinal canal at the level of C2 is large,a hangman’s fracture does not cause neurologic injury

24. Laminar fracture(usuallystable) Occipital condyle fractures (usually stable)

25. Odontoid(dens) fractures (type II and III are unstable) Frequently involves other injuries to the cervical spine and multisystem trauma. Conscious patients will usually describe immediate and severe high cervical pain with musclespasm.The pain may radiate to the occiput. Neurologic injury ispresent in 18% to25% of cases with odontoid fractures ranging from minimal sensoryor motor loss to quadriplegia T1 T2 T3

26. Atlanto-occipitaldissociation (AOD) ( highly unstable ) Translational fracturedislocation (unstable) - Thoracolumbar Mortality is high The classic presentation is paralysis of upper extremities with lack of Lower Extremity paralysis or weakness

27. Sacrum and coccyx fracture Sacral fracture Coccyx fracture Usually associated with pelvic fractures Can present with bowel/bladder incontenence

28. Spinal stability spinal injury is considered unstable if normal physical load cause further neurological damage, chronic pain and deformity Instability Exists if any of two columns are disrupted. In T-L stability if middle column is intact, # is usually stable.

29. stable V/s unstable injuries STABLE Injuries vertebral components won't be displaced by normal movements. An undamaged spinal cord is not in danger. There is no development of incapacitating deformity or pain UNSTABLE injuries Further displacement of the injury may occur Loss of 50% of vertebral height Angulation of thoracolumbar junction of >20 degrees Failure of at least 2 of Denis's 3 columns. compression fracture of three sequential vertebrae can lead to post traumatic kyphosis

30. SPINAL CORD INJURIES: It is 2 types Primary injury: mechanical forces that directly traumatize the spinal cord and vasculature. secondary injury: primary insults sets into notion a series of vascular and chemical processes. Initial phase is charatesied by hemorrhage into the cord and formation of edema at the injured site and surrounding region Local Spinal cord ischemia due to secondary to vasospasm and thrombosis. of small are reterioles within gray white matter Tissue degeneration phase develops within hours of injury

31. SPINAL CORD LESIONS COMPLETE LESION: The American Spinal Injury Association defines a complete neurologic lesion as the absence of sensory and motor function below the level of injury INCOMPLETE LESION: lesion is incomplete if sensory, motor, or both functions are partially present below the neurologic level of injury This may consist only of sacral sensation at the anal mucocutaneous junction or voluntary contraction of the external anal sphincter upon digital examination.

32. Complete lesions have a minimal chance of functional motor recovery. Patients with incomplete lesions are expected to have at least some degree of recovery. The differentiation between complete and incomplete spinal cord damage may be complicated by the presence of spinal shock. TYPES: 1 Central cord syndrome 2 Anterior Spinal cord syndrome 3 Posterior Cord Syndrome 4 Brown-Sequard Syndrome. 5 Cauda Equina Syndrome

33. overview of Tracts & clinical features Damage to the corticospinal tract neurons (upper motor neurons) in the spinal cord results in ipsilateral clinical findings such as muscle weakness, spasticity, increased deep tendon reflexes, and a Babinski’s sign. when the spinothalamic tract is damaged, the patient experiences loss of pain and temperature sensation in the contralateral half of the body The (pain and temperature) sensory loss begins one or two segments below the level of the damage.

34. The dorsal columns transmit vibration and proprioceptive information. Injury to one side of the dorsal columns will result in ipsilateral loss of vibration and position sense light touch is not completely lost unless there is Damage to both the spinothalamic tracts and the dorsal columns.

35. CAUDA EQUINA Syndrome Cauda equina syndrome is not a true spinal cord syndrome because the cauda equina is composed entirely of lumbar, sacral, and coccygeal nerve roots injuries to this region produce peripheral nerve injuries Symptoms and signs may include bowel and/or bladder dysfunction, decreased anal sphincter tone “saddle anesthesia” -sensory deficit over the perineum, buttocks, and inner thighs variable motor and sensory loss in the lower extremities Decreased lower extremity reflexes, and sciatica

36. shock in spinal Trauma Identification of shock : Three types of Shock may occur in Spinal Trauma Hypovolaemic shock : Presents with hypotension. tachycardia, cold calmmy peripheries, caused by hemorrhage. Neurogenic shock : Hypotension with Normal heart rate or bradycardia and warm peripheries caused by unopposed vagal tone resulting from cervical spinal cord injury above the level of the sympathetic outflow (C7/T1) Spinal Shock : Characterized by paralysis, hypotonia, and a reflexia. Lasts for only 24 hours some times days weeks Maximum upto 6 months.when it starts to resolve bulbo cavernosus reflex returns

37. Spinal Trauma: Management prinicipals 1) Immobilisation 2 Intravenous fluids 3 medications 4 Early advise, prompt referral/Transfer ED acute care priority: Avoid secondary in Spinal injury

38. IMMOBILISE cervical collar, long spinal board, bolsters and tape Remove from Spinal board as soon as possible (ideally 2 hours, Beaware pressure points decubitus ulcers ) Logroll maintaining neutral of gment of entire Spine (four or more helpers required with avg 70 Kg pt) spinal immobilization is NOT recommended for fully conscious, neurologically intact patients with isolated penetrating neck injury

39. INITIAL ED STABILIZATION AIRWAY AND BREATHING The higher the level of spinal injury, the more likely is the need for early airway intervention. some experts recommend that any patient with an injury at C5 or above should have the airway secured by endotracheal intubation. Do not hesitate to substitute manual in-line stabilization if the collar is compromising the airway. Maintain manual in-line spinal stabilization while intubating CIRCULATION: IV fluids 20-30 ml/kg or blood transfusion for profund blood loss

40. Basic patient Assessment Approach every patient in the same manner using ATLS Assume every trauma patient has a spinal injury until proven otherwise. All Accessment, Resuscitation and Life Saving procedures must be performed with full spinal immobilization Signs of spinal injury : Polytrauma patient, Neurological deficit, multiple injuries, head injuries, facial injuries, high energy injury, Abdominal Bruising from a Seatbelt.

41. signs and symptoms pain (and bony tendress on Examination) Tingling, numbness and weakness in peripheries loss of sensation or paralysis below level of injury Impaired breathing -C3/4/5 (diaphragm ) Bowel and bladder incontenance priapism

42. Physical Examination Inspection & palpation of the spine Should include the Search for -swelling - Tenderness - skin bruises, lacerations, ecchymoses - open wounds - hematoma - Spinal alignment

43. Primary Survey Move patient off Spinal board as soon as clinically safe to do so Airway maintenance with C-spine immobilisation Definitive airway early if respiratory compromise (injury higher than C6 need intubation and ventilation) Breathing and ventilation - 15L/min oxygen (NRBM) + ventilatory Support -monitor RR, respiratory effort, cough.

44. Circulation with haemorrhage control -If hypotension: hypovolaemic v/s neurogenic shock - Assume hypovolaemia 1st : Search for Source bloods loss + replace fluids Disability -GCS/pupil - look for paralysis/paresis/priapism, anal sphincter tone/bulbocavernosus reflex Exposure/ Environment -Blood Sugar level and temperature - keep warm blankets

45. Adjuncts to primary survey ECG Trauma x-ray series: c-spine, LS spine, TL spine, Chest x-ray, pelvis with bll hip Bedside FAST Scan (? Source of bleeding) NCCT-brain, CT-cervical spine CT-whole spine Screening

46. Criteria for C-spine imaging

47. Secondary Survey Focused AMPLE history Ask for mechanison? - compression, flexion/distraction, hyperextension, rotation, shear injury Neurological deficits -Time of onset - Course (unchanged, progressive or improving) Does your neck or back hurt? Can you feel me touching your fingers & toes? Can you move your foot ?

48. Neurological evaluation American Spinal Injury Association (ASIA) Neurological Evaluation system is used and ASIA Chart is used. Motor Function assesses key muscle groups Grade (0-5) sensory Function assesses dermatomal map. (pinprick and light touch) Score 0-2 Rectal Examination -Anal Tone - voluntary anal contraction - Perianal sensation

49. CORTICOSTEROIDS High-dose methylprednisolone remains a controversial treatment in acute blunt spinal cord injury and should not be given routinely Not been found to be efficacious in penetrating spinal cord injury

50. Investigations CBC, Blood grouping, cross matching RFT, LFT, Serum Electrolyte CT and MRI studies MRI - In the presence of neurological defects, MRI is recommended to identify a possible Cord Lesion or a cord compression may be due to disc or fracture fragments or Epidural Hematoma

51. DISPOSITION OF SPINAL COLUMN INJURIES Obtain emergent consultation with a spine surgeon (neurosurgeon or orthopedic surgeon depending on the particular facility) on all spinal column fractures or ligamentous injuries, regardless of neurologic compromise.

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