SPINE TRAUMA BY ME SPINE TRAUMA BY ME.pptx

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1. SPINE INJURIES BY DR. DANNY BARAKAT

2. Spinal Injuries Spinal Column Injuries Injuries to Neural Structures (spinal cord, nerve roots) ±

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 30% Thoracolumbar 70% 50–60% of thoracolumbar fractures affect the transition T11–L2, 25–40% the thoracic spine and 10–14% the lower lumbar spine and sacrum

4. 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

5. Level of injury Is the most caudal segment with motor function at least 3 out of 5 AND pain and temperature sensation are present

6. Spinal Stability Clinical stability : the ability of the spine under loads to limit displacement and prevent injury to the cord and roots ,and also prevent the increase of deformity or pain due to structural changes Biomechanical stability : the ability of spine to resist forces

7. Biomechanics Three column theory of spinal stability by Denis Anterior : ALL, anterior annulus fibrosis, anterior ( anterior half of VB ) Middle :PLL, posterior annulus fibrosis, posterior body( Posterior half of VB) and pedicles Posterior : Lig flavum + supraspinous & Interspinous lig + facet joint and capsule+ posterior arch

8. Management in the field assess airway, breathing, circulation (ABCs…) then : Log rolling and cervical immobilization

9. Maintain oxygenation

10. Management in hospital 1: immobilization 2:hypotesion : fluids as necessary , dopamine if needed , atropine for bradycardia , electrolyts 3: oxygenation 4: NG tube to suction 5 : FOLEY catheter 6: DVT prophylaxis 7: motor and sensory evaluation 8: radiographic evaluation 9: medical management specific to spine

11. Key muscles for motor level classilflcatlon (EXTREMITIES )

12. RECTAL EXAM 1. external anal sphincter is tested by insertion of the examiner's finger A. perceived sensation is recorded as present or absent. Any sensation felt by the patient indicates that the injury is sensory incomplete B. note resting sphincter tone and any voluntary sphincter contraction 2. bulbocavernosus reflex (BC) contraction of anal sphincter in response to pinching penile shaft, or in response to tug on Foley catheter is normal (must be differentiated from the movement of the catheter balloon). Presence of BC reflex used to be taken as an indication of an incomplete injury, but its presence alone is no longer considered to have a good prognosis for recovery.

13. still highly controversal even among experts 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 47 h Methylprednislone Solu-Medrol ®

14. Cervical collar Cervical collar is not indicated when patient : Alert ,awake, no signs or symptoms Is not indicated in patients with : No mental changes No pain or midline tenderness No neurologic deficit No significant associated injuries Radiographic evaluation

15. 2 RT Normal Cervical Spine Four lines should be examined Any malalignment indicates an occult fracture or ligamentous injury and should trigger a CT scan 1 = anterior vertebral line 2 = posterior vertebral line 3 = spinolaminar line 4 = posterior spinous line

16. 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

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

18. 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 .

19. Degree of kyphosis can be measured using Cobb Measurement

20. Mechanism of injury

21. Mechanism of Injury Flexion Extension Distraction compression rotation

22. Hyper flexion Injuries: Hyperextension Injuries : Compression Injuries : Bilateral facet dislocation Avulsion fracture Jefferson’s fracture (axial load+ flexion ) Odontoid process fracture Fracture of the posterior arch of C1 Burst fracture Simple wedge fracture Hangman’s fracture Flexion teardrop fracture Articular pillar/facet fractures Posterior fracture-dislocation of the dens Spinous process fractures Anterior fracture-dislocation of the dens Classification of spinal Injuries

23. Rotation Injuries: Lateral Flexion Injuries: Shearing Injuries: Distraction Injuries Lamina or facet fractures (extension) Transverse process fractures (m/c) Fracture/dislocation in thoracic and lumbar spine Chance fractures Rotary atlantoaxial fixation Atlanto-occipital dislocation Atlanto -occipital dislocation Unilateral facet dislocation (flexion) Classification of Injuries

24. early closed reduction of C-spine fracture/dislocation injuries with craniocervical traction to restore anatomic alignment in awake patients Not recommended : closed reduction in patients with an additional rostral injury • patients with C-spine fracture-dislocation who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo cervical MRI before attempted reduction . The presence of a significant herniated disc in this setting is a relative indication for anterior decompression before reduction • cervical MRI is also recommended for patients who fail attempts at closed reduction INITIAL CLOSED REDUCTION IN FRACTURE\DISLOCATION CERVICAL SCI

25. Cervical Traction Weights: initial weight : 3 x cervical vertebral level (in lbs), increase 5-10 lb usually at 10-15 minute intervals until desired alignment is attained Lb = 454 grams Application: Shave the hair above the ear region Local anaesthetic Avoid masseter Avoid Temporal artery incision above ear in line with auditory meatus Screw in pin until it just perforates outer table skull Tie on rope Attach weights

26. Whiplash injury Traumatic soft tissue injury due to hyperflextion Grade 1: neck pain , stiffness ,no signs Grade 2: above + reduced neck motion ,point tenderness Grade 3: above + weakness , sensory deficit Grade 4: not whiplash , above + fracture or dislocation

27. Grade 1 : plain x ray , remove collar if normal Grade 2 : plain x ray , collar for 72 h if normal Grade 3 -4 : x ray , CT , MRI, collar for 96 h if normal evaluations NSAIDs could be given for all grades for 3 weeks Encourage regular activities ASAP for 1-2-3 grades

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

29. 60 % Isolated C1, 40% combined with C2 From Axial load Unstable if transverse ligament (TAL) is disrupted usually no neurologic deficit (fragments forced outward, large canal) Burst fracture of the atlas 2-4 points fracture Involves both the posterior and anterior arches Treatment : stable (TAL intact ): CERVICAL COLLAR FOR 12 WEEKS, HALO unstable (TAL disrupted ) :SURGICAL FUSION Jefferson’s Fracture ( C1 Fractures )

30. Fusion options when surgery is indicated : 1. unilateral ring or anterior C 1 arch fractures: Cl-2 fusion 2. multiple ring fractures or posterior C1 arch fractures: occipital-cervical fusion, C1-C2 fusion

31. Entry Point : midpoint of the inferior part of lateral mass of C1 17 degrees medially, 22 rostrally SCREW : 3.5 – 4 mm diameter, length is determined from pre op CT scan

32. ENTRY POINT: 3-4 mm above the inferior margin of C2 inferior facet 20-30 medially , 25 superiorly . 3.5 mm diameter screw , 15-20 mm length

33. INTERSPINOUS FUSION Used as primary fixation for C1-C2 fusion CANNOT be used if posterior arch of C1 or C2 is fractured

34. C1 Lateral Mass / C2 Pedicle Screw-Rod Fixation

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

36. Hangman's Fracture Hangman's fracture involves a bilateral arch fracture of C2 ( pars interarticularis ) with variable C2 on C3 displacement. Due to hyperextension + axial loading Most are stable Clinical Features : not highly specific symptoms, diffuse neck pain with stiffness relative sparing of the spinal cord because of the capacious bony canal.

37. EVALUATION Cervical CT : with sagittal & coronal reconstructions should be done to fully assess the fracture. CTA : should be done to evaluate the vertebral arteries if fracture extends through foramen transversarium Angiography or MBA may be done as an alternative to CTA MRI: cervical MRl should be done to look for C2-3 disc disruption (a marker for instability)

38. Type Description Mechanism of Injury Type I Stable. Fractures through the pars with 3 mm or less displacement of C2 on C3 .NO angulation Axial loading and then extension. Type II Unstable. Significant displacement of C2 on C3 (>3 mm or >11 degree angulation ). Disruption of PLL. Axial loading, extension, and then rebound flexion. Type IIA Less displaced but more angulated than II.>15 degree Same as II. Type III Type 2 + C2-C3 facet capsules disruption Unclear , may be Compression and flexion.

39. Treatment type I may be treated in a rigid collar Philadelphia for 3 months. Remainder: C2 (“hangman’s”) fracture immobilised and treated in a halo brace compatible with the use of CT and MRI Reduce with gentle cervical traction (most reduce with : 30 lbs) with the head in slight extension (preferably in halo ring Surgery is required for 1. inability to reduce the fracture ( Levine Type II or III) 2. failure of external immobilization 3. traumatic C2-3 disc herniation with compromise of the spinal cord

40. Surgical Procedures 1. C1-C2 arthrodesis ( Posterior Approach C1-C2 wiring, or lateral mass screws ) 2 : C1- C3 fusion if the C2 C3 disc is disrupted (posterior approach) 3. C2-C3 anterior discectomy with fusion and plate . (anterior approach ) .

41. Odontoid Process Fractures Type I Stable , cervical immobilization collar , Halo Type 2 usually unstable , needs surgical fusion ( odontoid screw , c1-c2 arthodesis wiring \fusion with screws) Type 3 Stable , collar , Halo, but could be unstable treatment

42. Teardrop Fracture Flexion and compression fracture 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. Unstable

43. Obtain X rays , CT scan : through the fractured vertebra to evaluate for associated fractures MRI : to assesses the integrity of the disc and gives some information about the posterior ligaments Treatment : if disc and ligaments are intact HALO if injured Surgical fusion When the injury is primarily posterior: then posterior approach . Severe injuries with canal compromise often require a combined anterior decompression and fusion (performed first) followed by posterior fusion

44. C3-C6 LATERAL MASS SCREWS method of AN ENTRY POINT : 1 mm medial to midpoint of lateral mass , 15 degrees cephalad – 30 laterally 3.5 mm diameter screw, 14-16 mm length

45. Avulsion fracture chip of bone off anterior inferior VB Caused by traction of ALL in hyperextension. Stable distinguishing from tear drop fracture Neck pain without neurologic deficit treatment rigid collar (e.g. Philadelphia collar ), and repeat the films in 4-7 days (i.e. after the pain has subsided to be certain that alignment is not being maintained by cervical muscle spasm from pain) , remove collar if 2nd set of films is normal.

46. Subluxation If >3.5 mm of one vertebral body on another Or > 11 degree angulation Indicates ligamentous injury If < 3.5 mm and <11 angulation then optain flexion extension x rays , if no abnormal movements … remove collar

47. Radiographic Features 1 , widening of interspinous distance 2 , loss of parallelism between facet joints; 3 , sagittal displacement of a vertebral body >3.5 mm. 4 , angular displacement ( sagittal plane rotation) >11° compared with the adjacent interspaces

48. Locked facets Bilateral …. extreme hyperflexion Unilateral …. Flexion + rotation It is associated with a very high risk of cord injury Bilateral usually produces >50% Subluxation Unstable

49. Initial Treatment : reduction is recommended Then A: posterior arthrodesis with screws and rods , Or B: anterior surgical arthrodesis with plate fixation when there is a herniated disc OR, C : both ant+ post approaches If above treatment is not available then cervical traction with bed rest Unilateral : “ bowtie” or “butterfly” appearance

50. Follow up Schedule

51. MINOR AND MAJOR INJURIES Classification into : Minor injuries : involve only one part of a column Isolated Fracture of : transverse process , facet , pars , spinous process , lamina usually stable Thoracic & lumbar spine fractures

52. Treatment of stable anterior or middle column thoracolumbar spine injury Treat initially with analgesics and bed-rest for 1-3 weeks Brace for 12 weeks Pain relieve is a good indication to start motion with or without brace serial X rays to rule out progressive deformity

53. Major injuries : 1 : compression fractures : failure of anterior column , middle and posterior INTACT , usually stable , no neurologic deficit Unstable if : 1 :>50% loss of VB height 2: >30 degree kyphosis or progressive kyphosis 3: multi levels 3 or more C ontiguous fractures

54. 2 : burst fractures : axial load ( compression) , failure of anterior and middle columns , VB height Posterior VB wall retropulsed in spinal canal causing injury to neural structures Usually unstable Thoracolumbar (T12) fracture. burst fracture,

55. Surgery for burst fractures Is indicated with any of VB height < 50% kyphosis > 20 degree Neurologic deficit ( incomplete ) Progressive kyphosis residual canal diameters < 50% of normal

56. 3 : seat belt fracture : compression of anterior column and distraction failure of both middle and posterior column A Chance fracture (one level through bone )is commonly associated with use of a lap seat belt in high-speed MVC Usually no neurologic deficit Treat most with external Immobilization Surgery when 1: neurologic deficit 2: instability

57. 4 : fracture – dislocation : failure of all three columns due to compression, rotation , shear Causes subluxation or dislocation Usually unstable Increased interspinous distance Surgery when : VB height < 50% kyphosis > 25% Neurologic deficit

58. Surgical treatment Neural Decompression Stabilization Fusion

59. ENTRY POINT : medio -lateral : mid facet line . Craniocaudal : just where the superior facet joins the transverse process 5-10° medially and 10-20° caudally Screws : 4.5 – 5.5 mm diameter, length: 20-26 mm

60. ENTRY POINT : at the base of the transverse process , at the intersection of the center of the transverse process and the superior facet(lateral facet ). Lumbar vertebral number multiplied by 5° medially rostral -caudal direction is determined by fluoroscopy 5.5 mm diameter screws or more . lengths vary from 40 to 55 mm

61. Fragments within the canal : if the PLL is intact , distraction may be able to "pull" the fragments back into their normal position ,although this is not assured. And has a better chance of succeeding if performed within 48 hours of injury If not intact then they should be impacted anteriorly out of the canal

62. if there is : good bone quality , then one can fuse/rod one level above and one below the fracture Poor bone quality : an option is to rod 2 levels above and below the fracture remove the hardware when the fusion is solid (e.g. at ... one year)

63. For those not undergoing surgery and for post OP patients Bed rest for 1-6 weeks with brace Movement with brace for 4-6 months Serial x rays to rule out progressive deformity

64. Degree of injury Complete: total loss of sensory & motor functions below level of injury 3 % will develop some recovery within 24 h . However, recovery is essentially zero after 72 h.

65. Incomplete: any residual motor or sensory function below level of injury . And this has 4 types (syndromes) : Anterior cord syndrome Posterior cord syndrome Brown sequard syndrome Central cord syndrome

66. Signs of incomplete lesion : 1: sensation (including position sense) or 2 : voluntary movement in the Les 3: sacral sparing : preserved sensation around the anus, voluntary rectal sphincter contraction, or voluntary toe flexion • an injury does not qualify as incomplete with preserved sacral reflexes alone

67. SPINAL SHOCK This term is often used in two completely different senses: 1. hypotension (shock) that follows spinal cord injury Caused by multiple factors: A . interruption of sympathetics : implies spinal cord injury above T1 1. loss of vascular tone (vasoconstrictors) 2. leaves parasympathetics relatively unopposed causing bradycardia B. blood loss from associated wounds- true hypovolemia 2. transient loss of all neurologic function (including segmental and Polysynaptic reflex activity and autonomic function) below the level of the SCI ..... flaccid paralysis and areflexia lasting varying periods ( usually 1-2 weeks , occasionally several months and sometimes permanently),

68. Central Cord Syndrome Most common incomplete cord syndrome. Hyperextension injury Older age with cervical spondylosis Motor : Upper extremity deficit is greater than lower extremity deficit , because the lower extremity corticospinal tracts are located lateral in the cord . sensory : varying degrees of disturbance

69. Brown- Sequard Syndrome may result from rotational injury such as fracture-dislocation or from penetrating trauma Ipsilateral : Impaired or loss of movement, touch, pressure and vibration Contralateral : loss of pain and temperature sensation Best prognosis between incomplete injuries

70. Anterior Spinal Cord Syndrome Seen in flexion injuries e.g. burst fracture, flexion tear drop fracture and herniated disk. Some say this is the most common incomplete injury Anterior spinal artery compression This causes damage to the” corticospinal tracts …….. motor paralysis spinothalamic tracts ……. loss of pain, temperature The worst prognosis between incomplete injuries

71. 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.

72. Thank You For Your Listening