SPINAL CORD

INJURY

Presenter: Dr KESHENI LEMI

SUPERVISOR :ATYAM SOLOMON ,ORTHOPEDIC SURGEON
OUTLINE
 Clinical anatomy
 Epidemiology
 Risk factors\Causes
 Mechanism of injury\ Pathophysiology
 Classifications
 Common Fractures
 Clinical Features
 Investigations
 Management
 Complications
 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 1st lumbar
vertebra or the upper border of the 2nd
lumbar vertebra or in between (in adults)
 Age variations in the length of spinal
cord

 At the 3rd month of pregnancy : it

occupies the full length of the vertebral
canal

 At full term (end) of pregnancy : it

reaches the level of the 3rd lumbar
vertebra

 In adults : it reaches the level of the

lower border of the 1st lumbar vertebra
 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
End of the spinal cord
 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
 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)
 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)
Components of spinal
nerves
Components of spinal
nerves
 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)
 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)
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.
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.
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
 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.
1. hypotension,
2. hypoxia,
3. spinal instability and/or
4. persistent compression of the neural elements.
Management of
5. a spinal cord injury must focus on minimising secondary
injury.
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
 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
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.
 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.
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 .
 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.
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
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.
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.
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.
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.
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 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. Neurologic deficit can result from
retropulsion of middle column bone fragments into the
spinal canal, or from subluxation causing decreased
canal diameter.
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
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
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.
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.
 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.
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.
 Motor scoring system

GRADE D5ESCRIPTION
0 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
DIAGNOSTIC IMAGING
 X-ray
 Ct scan

 MRI

 E fast Us

 Basic investigations

Indications for C-spine Films:

1. Tenderness
2. Neurologic defecit
3. Forceful Mechanism of injury
4. Distracting injury
5. Altered sensorium
Interpretation of Lateral Plain
Film
 Mnemonic AABCS
 Adequacy
 Alignment
 Bones
 Cartilage
 Soft Tissue
Interpreting Lateral Plain
Film
 Adequacy
 Should see C7-T1
junction
 If not get
swimmer’s view
or CT
Swimmer’s View
Interpreting lateral Plain
Film
 Alignment
 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
Alignment
Bones
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
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.
 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.
 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
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.
Complications of spinal injury

Organ Complications
System
Cardiovascular Bradycardia/ dysrhythmia, Cardiac arrest
Cardiogenic pulmonary edema
Pulmonary Hypoventilation/respiratory failure, Poor secretion
control
Acute respiratory distress syndrome, Aspiration,
Pneumonia
Gastrointestin Gastric dysmotility, Adynamic ileus, Gastritis and
al ulceration, Pancreatitis
Hematologic Venothromboembolism
Neurologic Neurogenic shock, Depression, Posttraumatic stress
disorder
Anxiety, Autonomic dysreflexia
Genitourinary Bladder dysfunction, Urinary tract infection, Priapism
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 surgery 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, Indiae-ma ii:
[email protected] 6thedit.
 Kenneth L. Mattox, MD David V. Feliciano, MD, Ernest E. Moore, MD, TRAUMA,
8th 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
THANK
YOU