1 Spine-General Principles

Main concern in any spinal injury is not spine itself but neurological elements (spinal cord, nerve

roots and cauda equina). If there is no neurological complication, precautions must be taken to see that this is avoided at all stages. If there is incomplete paraplegia, see that no deterioration is allowed to occur. If paraplegia is complete, prognosis regarding potential recovery must be firmly established as early as possible. Spine-Anatomical features Elements comprise of vertebral body composed of cancellous bone covered with outer shell of cortical bone, horseshoe-shaped neural arch, 2 articular masses or processes which take part in facet (interarticular) joints, and transverse and spinous processes. These form a protective bony covering for cord and issuing nerve roots. Neural arch is divided by articular processes into pedicles and laminae.

These vertebra are held together by inter spinous, supra spinous, inter transverse, annular

ligaments, facet joint, capsular ligament and ligamentum flavum. IS and SS ligaments are of paramount importance, and form so called posterior ligament complex. If this is torn, other ligaments offer little resistance and spine may sublux or dislocate. Subluxation may also occur if neural arch or articular facets are # and in either case the spine is unstable.

In instable spine, neurological structures may be damaged, and of they escape initially, they remain

at risk and it is vital to ensure that delayed neurological involvement does not occur. If neural arch, articular facets and PLC remain intact, injury is described as stable, neurological damage is uncommon, and prognosis is generally excellent. Exception include burst # of spine, some lateral wedge # and extension injuries of cervical spine.

2 Cervical spine-Diagnosis C/O of neck, occipital or shoulder pain after trauma, torticollis, restriction of neck movements or supports head with hands or is unconscious after head injury.

Cervical spine-Initial management First safeguard the cord by controlling neck movements. Simplest is cervical collar. At road side, an adequate collar is made from rolled newspaper stuffed into nylon stocking and wrapped round the neck. Head may be supported by sand bags. Do not allow the head to flex forwards, and do not hyperextend. In conscious patient quickly check movements in all four limbs.

If there is some evidence of neurological involvement, do not check range of cervical motion. Take
x-rays supporting the head during positioning (go with the patient) and make sure that spine is not forced into flexion. For initial screening, AP, lateral and through the open mouth view of C1 and C2 should be taken.

If these films appear normal, proceed further examination of neck for localizing tenderness,

restriction of movements and protective spasm and thorough neurological examination. If this is normal, patient treated with cervical collar with F/up review in 1 week.

3 Cervical spine-Initial management If there is persistent limitation of movements or evidence of neurological disturbance, 2 more lateral views, one in flexion and one in extension, and right and left oblique views of cervical spine taken. Upper border of T1 must be seen and do not accept poor quality films. CT if available, may provide valuable information. Classification of cervical spine injuries According to mechanism of injury; flexion, flexion and rotation, extension and compression injury.

Causes of flexion and flexion rotation injuries Falls on back of head leading to flexion of neck as in motorcycle spills, diving in shallow water, pole vaulting and rugby football; blows on back of head from falling objects as in building and mining industries; rapid deceleration in head-on car accidents.

Flexion injury: Stable anterior wedge # Vertebral body is wedged anteriorly, posterior part is generally intact. Before the injury can be declared stable there must be no evidence of injury to posterior ligament complex, no separation or avulsion of vertebral spines or clinical evidence of ligament tear, no damage to neural arches or facets. In addition, flexion and extension lateral views must be taken which confirms no vertebral instability.

If these criteria are satisfied, neurological disturbance is rare and prognosis is excellent. Treat with

cervical collar for 6 weeks. Rarely, when there is lateral wedging there may be troublesome nerve root involvement usually with mainly sensory disturbance in corresponding dermatome. If instability is at all suspected, treat it as a cervical dislocation.

4 Flexion rotation injuries: Unilateral dislocation with a locked facet joint One facet joint dislocates, so that in lateral view, one vertebral body is seen to overlap the one below by about 1/3rd. AP may not be helpful, or it may show mal alignment of spinous processes. Oblique views confirm the diagnosis. On one side columnar arrangement of bodies, foramina and facet joints will be regular while on other side it will be broken.
Damage to PLC is variable, and after reduction these injuries may be quite stable but note: if there

is an associated # of facet joint, the injury is most certainly unstable and fusion will be required after reduction. Clinically, head is slightly rotated and inclined to side, away from locked facet. There is great pain with radiation due to pressure on nerve root at level of affected joint, and there may be cord involvement.

Unilateral dislocation : Treatment Initial aim is to reduce dislocation with well controlled traction. Under G/A, head is well supported and x-ray facility preferably IITV is kept ready. Place the thumbs under the jaw, clasp the fingers behind occiput, and apply firm traction in lateral flexion away from side of locked facet i.e. in the direction the head is usually inclined.

Maintaining traction, bring the head into midline position, correcting the rotation element before

lateral flexion. Release the traction, support the head while check x-rays are taken. If reduction has not been achieved, repeat the maneuver with greater anesthetic relaxation.

Unilateral dislocation : Treatment Once reduction is achieved, a cervical collar is applied and worn continuously for 6 weeks. Fortnightly x-rays taken and flexion and extension lateral views at end of 6 weeks. If there is any evidence of late subluxation the patient should be admitted for local cervical fusion. F/R injuries: Unstable injuries

Commonest is one where there is pure cervical dislocation without #. Displacement may be

severe, frequently locking of both facets. Damage to PLC is always present and is obvious from degree of vertebral displacement.

Other evidence of instability with disruption of PLC, like avulsion # of spinous process, widening of
gap between two spinous processes or forward slip of vertebra on flexion of spine compared with extension views. Unstable injuries-Treatment Unstable injuries without # require fusion; skull traction is required to achieve and maintain reduction and should be applied without delay. Shave the skin around the proposed insertion points (approximately 6-7 cm above the external auditory meati) and infiltrate the areas deeply on both sides with LA.

Make a small incision (about 1 cm) on each side down to bone. Bleeding is usually brisk, but

controlled by firm local pressure. Now insert one point holder through temporalis muscle fibers until it is contact with skull. Straighten out the Cones caliper and close it while guiding the second point Cone holder through skin wound. Oscillate the caliper slightly to allow its tapered end to part temporalis muscle on second side. Close the caliper until both point holders are in firm but not hard contact with the skull.

Now screw the points in such that they protrude only 3 mm to penetrate the outer cortex only,

tighten them with key. If points fail to enter, either they are blunt or the bone is unduly hard. In these circumstances, a small awl may be used as starter, taking great care to avoid penetration of inner cortex. Now seal wounds with strip of gauze soaked in Nobecutane.

Unstable injuries-Treatment-Other traction devices Blackburn calipers are designed to hook into diploes of skull, and a trephine is used to remove a tiny lid of outer cortex. Crutchfield traction tongs are inserted nearer the vertex than the other two devices. They are also inserted into the outer cortex of skull bone after making a hole in it either by a drill or awl.

Unstable injuries-Reduction If reduction is required, some surgeons prefer G/A with good relaxation. Head is supported and firm traction is applied in neutral position or slight flexion to unlock facets. Maintaining traction, neck is slowly extended. Hand supporting occiput may be moved down the neck to use it as fulcrum. The traction is then slowly reduced, and while maintaining little traction, the position is checked with x-ray.

Alternatively, continuous traction may be used to overcome muscle tension and unlock overriding
facets. Direction of traction may be controlled by altering the position of traction pulley or by use of pads under the head or shoulders. Amount of traction is adjusted by weights. Duration of maximal traction is monitored by x-rays.

Better arrangement is with patient in a sitting up position. Traction is more efficient being countered

by body weight and if paraplegic, breathing is easier as diaphragm is unobstructed. Weight required vary from 7 kg for light adult woman to 14 kg for a heavy man. Line of traction should start in neutral position or slight flexion. In recently injured patient, x-rays to check progress should be taken every 15 minutes.

As soon as neck has been stretched sufficiently to allow unlocking of facets, neck should be

extended to complete the reduction. If injury is long standing, 1-3 weeks, progress will be much slower and in extreme cases can extend to days. As soon as check x-rays confirm reduction, traction should be reduced to about 2.5 kg. On no account should the neck be allowed to over distract.

Sillars method : Patient under G/A placed on OT table with break at shoulder level. Shoulder rests Sillar

are fitted. Traction cord stretched between skull calipers and fixed object. Cord is tightened and when sufficient tension is present, end of table is dropped. Spine is visualized under IITV, traction increased till facets unlock. Thereafter cervical spine is extended by tilting table and traction reduced. Advantage of this method is rapid reduction and fine linear control of spine.

Unstable injuries-Reduction failure Fresh injuries failures are rare. But difficult in 3-4 weeks late cases. Assuming that there is no complete paraplegia, open reduction is attempted by local trimming of those parts of facets which are blocking reduction (facetectomy). In very long standing dislocations, spinal stability is more important than accurate reduction and the spine may be fused in dislocated position if reduction cannot be obtained.

Unstable injuries-After care When there is dislocation without #, PLC never regains its former strength. Spontaneous recurrence of displacement is inevitable unless posterior fusion is done. Fusion can be delayed until neurological picture is clear, meantime traction should be maintained. No neurological disturbance, spinal fusion after few days. Incomplete paraplegia, reasonable delay of 1-2 weeks. Complete paraplegia, fusion is not required, traction may be discontinued and collar substituted after 4-6 weeks. Where injury is accompanied by #, union in this # may result in stability (e.g. # of base of spinous process), traction may be continued until union occurs say after 8 weeks. Final stability of spine should nevertheless always be checked by flexion and extension lateral views. Cervical Fusion When there is PLC rupture, anterior cervical fusion is unreliable, and posterior fusion is advocated. Traction is maintained, after carefully controlled intubation, patient is turned prone, head is supported in head ring, cervical spines are exposed through midline incision. Ruptured PLC is identified and adjacent spinous processes, laminae and facet joint rawed. Spines are wired together. Two iliac bone grafts are placed on either side of spines, bridging them. Cancellous bone chips are packed into area before closure. Traction is continued for 6-8 weeks and collar substituted when there is evidence of fusion.

Extension injuries-Mechanism Fall downstairs striking the forehead against the ground, front impact car accidents where forehead strikes the car roof or bonnet and in rear impact car accidents in which the neck extends due to inertia of head. Extension injuries-Pathology Common in middle aged and elderly who suffer from cervical spondylosis. OA rigidity in spine may lead to excessive concentration of violence at any area of spine retaining mobility. Similar predisposing factor is ankylosing spondylitis, severe RA, or congenital deformity of spine with localized areas of fusion (e.g. Klippel-Feil syndrome). Neck hyper extends leading to tearing or avulsion of ALL. During extension, cord may be stretched at level of vertebral lesion or when vertebra snap together again, cord may be nipped by backward projecting osteophytes. Stretching and kinking of spinal vessels may lead to extensive spreading thrombosis. Cord damage is often diffuse and may not correspond exactly with level of injury. Motor loss, tends to be more in arms than legs. Temperature and pain conduction are more likely to be affected than proprioception and light touch, which are frequently spared.

Extension injuries-Diagnosis H/O injury, pain in neck and complaint of weakness in arms are suggestive. Where causal force is anterior, bruising or laceration of the forehead is an invaluable sign. Extension injuries-Radiographs Spontaneous reduction is the rule, so x-rays may be quite normal. Nevertheless, evidence of injury may be present. ALL may avulse its attachment to vertebral body or an osteophyte. Hemorrhage may lead to anterior displacement of pharyngeal shadow. Rarely, # of laminae or spinous processes or tearing open of vertebral body. Extension injuries-Treatment Extension injuries are stable. Local treatment consists of judicious use of collar till local pain and cervical muscle spasm settle. General treatment is that of neurological problem which may be minor or profound. Compression # of cervical spine-Mechanisms

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Heavy objects falling on the head, vertex striking the ground as in falls, diving and other athletic

accidents. Head striking the roof of car as in head on car accidents. Compression # of cervical spine-Diagnosis H/O injury may be suggestive. There may be tell tale lacerations on crown of head. Complaint of pain in neck should lead to taking of radiographs of neck which will clarify the diagnosis. Compression # of cervical spine-Radiographs Appearances are dependant on degree of causal violence. If forces are moderate, a fissure # of vertebral body most obvious in AP views. More severe injuries, body may be comminuted and flattened. Fragments of body may be extruded in any direction, when this happens the cord may be endangered. CT scan is of particular importance in clarifying the extent of # of this type. Compression # of cervical spine-Neurological involvement Most vulnerable part of cord lies anteriorly, affecting first motor supply of UL before motor pathways to LL; hence paralysis tends to be maximal in UL. Next to be involved are spinothalamic tracts carrying pain and temperature and lastly the posterior columns (proprioception and light touch).

Compression # of cervical spine -Neurological assessment

Test all main muscle groups in UL & LL, skin and tendon reflexes, sensation to pin prick, light touch

and proprioception. If the paralysis is bilateral, symmetrical and complete, testing should be repeated meticulously at 6, 12 and 24 hrs post injury. No recovery after 24 hrs almost certainly indicates hopeless prognosis. A profound neurological loss cannot be declared complete unless proprioception and light touch have been most carefully assessed. Compression # of cervical spine Treatment PLC is intact and once these # have healed, there is no tendency to subsequent displacement. Best treated by cervical traction for 6 weeks until cancellous union has occurred. Traction also minimizes chances of backwards displacement of bone fragments. Laminectomy is sometimes carried out to allow removal of backward projecting bone fragments causing cord compression. This is fully justified in incomplete cord lesion, deteriorating neurological picture, local block on myelogram, confirmatory evidence of spinal encroachment on CT scan. Atlas & Axis AO subluxation & dislocation Traumatic lesions at this level is usually fatal, but a few survive. Subluxation from RA and spinal infections like TB are seen more frequently. Cervical fusion (occiput to C1 and C2) with a period of halo traction is generally advocated. # of Atlas Usual pattern of # is quadripartite, and produced as a result of severe downward pressure of occipital condyle on atlas. Such force may result from weight falling in head as in construction industry, head striking the roof of car in RTA or falling from height in to the heels.

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Clinically if patient is conscious, may resent sitting up and may support head with hands. C/O

severe occipital pain sue to local pressure on great occipital N. about 50% survive this injury without significant neurological involvement.

# of Atlas Radiographs Lateral view may show # of posterior arch. AP is generally unhelpful. Open mouth or through the mouth view is most valuable and reveal lateral displacement of lateral masses. Pain and resistance to all movements may lead to failure of this view. An oblique lateral centered on C3, AP and lateral tomography and CT scan may be helpful.

Congenital absence of part of posterior arch may cause confusion, but in itself is of no significance. Treatment : These cannot be reduced, with slight displacement, well fitting collar for 6 weeks with
observation in hospital for 2-3 weeks at least is desirable. With more severe displacements, 6 weeks skull traction is advisable. Transverse ligaments lesions Runs between 2 bony tubercles which lie between joint surfaces which articulate with occiput and those which articulate below with axis. The odontoid process articulates with anterior arch and TL prevents its backwards travel.

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Ligament may be torn in sudden flexion injuries, may become attenuated or rupture in RA or soft
tissue infections of neck in children. In either case risk to cord is great as it becomes pinched between posterior arch of atlas and odontoid process.

Transverse ligaments Diagnosis Suspected form history, pain in neck and head and presence of marked cervical spasm. Confirmed by x-rays. Plain lateral views show gap between posterior face of anterior arch and odontoid process. In adult normal is up to 4 mm and any gap more than this are pathological. There is also some degree of rotational deformity. Open mouth view show asymmetrical location of odontoid relative to lateral masses of atlas. If there still is doubt, flexion and extension lateral views taken. Any abnormal excursion of odontoid relative to anterior arch of atlas is diagnostic. If available, CT scan clarifies the relation between odontoid and anterior arch of atlas. Transverse ligaments Treatment Initially, skull traction of 3 kg in extension should be setup. In children, 6 weeks traction alone may suffice to restore stability. This is especially true where pathology has been due primarily to local infection and this has been in addition adequately dealt with.

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When pathology is secondary to RA, local cervical fusion is generally advised. Posterior arches of
C1 and C2 are rawed. 2 stout grafts from tibia or illiac crest are wired in position. Upper wires pass round the arch while lower is passed through hole drilled in spine of C2. Area is then packed with cancellous bone chips.

If posterior arch of C1 is frail, include occiput in grafted region; great care must be taken in passing

the fixing wires through holes drilled in the edge of foramen magnum. After surgery, traction is maintained for 6 weeks and collar is generally worn for further 2-3 months.

If dislocation is due to recent trauma, conservative treatment with halo traction for 8 weeks is

sufficient. Apparatus is cumbersome and patient must be well motivated. Complications in over 50% cases is recorded. When the device is finally removed, stability must be assessed with flexion and extension lateral views. If there is evidence of persisting instability, fusion is needed.

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Odontoid # - Classification Type I : Involve tip of peg, generally stable, good prognosis and require symptomatic treatment only. Type II : Involve junction of peg with body and are commonest. Type III : Run deeply into the body of C2, union fails to occur in about 1/4th of cases, so they must be handled carefully.

Odontoid # - Mechanism & Diagnosis

Result from sudden severe flexion or extension of neck (flexion and extension injuries). History is suggestive, site of pain and protective muscle spasm. Occasionally, original injury may be

ignored, and discovered only on investigation of advancing ataxia or other neurological disturbance. # shows clearly on open mouth AP views and/or standard lateral view. Confusion arises from certain congenital abnormalities.

Odontoid # - Congenital abnormalities Complete absence of process (predisposing to dislocation), hypoplasia or non fusion of odontoid process persisting as os odontoideum. Ossification centre of apex normally appears at 2 years with fusion occurring by 12 years. Rounded edges and separate articulation with atlas may help to distinguish from a #.

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Flexion injuries Atlas and dens displace anteriorly in relation to C2. There may be associated rotational injury. If # is at junction, incidence of non union is about 60% with risk of progressive subluxation and neurological involvement. Flexion injuries Treatment
In spite of risk of complications they are treated conservatively. Reduce by applying traction in

extension, using skull calipers. In older patients, good reduction should be aimed at, to lessen risks of non union. In younger patients, persistent displacement can remodel well. After 1-2 weeks in traction, it may be possible to mobilize patient; especially desirable in elderly patient who will not tolerate prolonged traction and confinement to bed.
A stout well fitting cervical collar used. In younger patient, better support is given with Minerva

plaster or halo pelvic traction. In all cases, they should be continued for 8 weeks. Stability should then be assessed with flexion and extension lateral views. Surgical treatment with fusion of C1 and C2 is indicated if conservative treatment fails, if case presents late, if good reduction cannot be achieved, where delay and complications of conservative management present greater risk than risk of primary surgery. Treat displacements of os odontoideum conservatively unless the forward slip is extensive or there are severe or progressive neurological signs. # of odontoid process in adults may be treated by experienced surgeon with screw fixation and grafting, using anteromedial approach. Extension injuries # with backward displacement is common in elderly and is relatively stable lesion. Treatment : If shift is slight, a collar for 8 weeks should suffice. If marked, apply traction in slight flexion with calipers, but slacken off weight as soon as reduction has been achieved to avoid distraction. After 2-4 weeks a collar may be substituted.

16 # of pedicles of C2 Occur in 2 distinct ways, extension and distraction of neck as in hanging. Similar and not always fatal, injuries in cyclists who are caught under chin by a tree branch or a rope. Neurological disturbance is usually profound.

Also caused by forcible extension of neck accompanied by compression, as in RTA if head strikes

the roof of vehicle and ricochets into extension. Neurological involvement is rare. These 2 types of injury are distinguished by history, site of bruising (neck or forehead) and neurological disturbance. # shows clearly on lateral views. Occasionally, there is spondylolisthesis of C2 on C3.

# of pedicles of C2 Treatment Extension injuries with distraction : Skull traction for 4-6 weeks to maintain position only. There is always the risk of further distraction and therefore important to limit traction to a max of 2 kg. if x-rays suggest distraction, or if neurological signs are advancing, traction must be abandoned and local fusion is advocated. Extension injuries with compression : If injury appears stable and there is no neurological disturbance, a well fitting collar should be worn for 6 weeks. If there is neurological involvement, 6 weeks period of skull traction should be advised. Thereafter if there is evidence of instability, fusion is indicated. Posterior and anterior fusion have both been advocated for C2 #. Isolated spinous process # # of spinous process of C7 or T1 (clay shovellers #) result from sudden muscular contraction shoveller (avulsion #). This is stable injury, and symptomatic treatment only is required like cervical collar for 23 weeks. It must be carefully distinguished from cervical dislocation with associated # (if in doubt, flexion and extension lateral views should be taken). Plaster fixation in cervical spine injuries Indicated as substitute for well fitting collar. Afford little more support and helpful in treating poorly motivated patient who may be tempted to remove the collar. Stockingette is applied to head and trunk, wool padding to pressure areas. Felt pads to chin and occiput are advisable.

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Four plaster slabs are prepared from 6 bandages, 2 are applied over shoulders, 1 from mid 6

scapular region to occiput and 1 over point of chin on to chest. The slabs are joined with circular bandages, stockingette and wool are turned down and trimmed. This plaster is best applied with patient seated on a stool.

Minerva plaster Although not giving as much support as halo pelvic fixation, is sometimes used as an alternative for dame indications. A plaster jacket is applied first, this is extended with slabs to form a collar, additional support is provided with head band and side struts. If to be worn for any length of time, head should be shaved.

Whiplash injuries

Occur almost exclusively in RTA. Classical pattern, spine is hyper extended following a rear impact collision and then rapidly flexed
as vehicle in which patient is traveling hits an object in front-usually another car. Term is now used loosely to cover virtually every neck injury without # sustained in RTA.

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Whiplash injuries Diagnosis Pain & stiffness in neck. Radiation of pain and numbness into arm and shoulder (indicating poorer prognosis) or to intra scapular region or occiput. Neck movements are restricted with widespread cervical tenderness, but objective neurological signs are rare. Whiplash injuries Radiographs Loss of usual cervical lordosis or localized kinking (of greater significance). Occasionally evidence of hyper extension (anterior osteophyte avulsion) or hyper flexion (flake # of spinous processes). Joint space narrowing and other spondylotic changes may appear 1-2 years after the incident and be related to it. Whiplash injuries Treatment Primarily conservative; only in most severe and persistent cases, local cervical fusion ever considered. Cervical collar and analgesics initially, if after 6-8 weeks symptoms are not controlled, local heat with or without cervical traction is advised. Symptoms are usually prolonged, often lasting 18 months to 3 years, in many may become permanent. Poor prognostic factors include pre existing spondylotic changes, localized kinking and positive neurological findings. # of Thoracic & Lumbar spine Mechanism : Result of forces which tend to produce flexion of spine. Rotational element is frequently present. Causes : Fall from height on heels, where normal curvatures of spine results in further flexion. Blows across the back and shoulders which cause the spine to jack-knife at TL junction e.g. injuries in mining and construction industries. Flexion and rotational forces transmitted to spine from road or vehicle impact in car and motorcycle accidents. Heavy lifting especially in elderly, where there is often osteoporosis or osteomalacia. Less commonly malignancy especially metastatis may be a factor, when the causal force may be slight or not even remembered.

# of Thoracic & Lumbar spine Diagnosis H/O of back pain after trauma, especially if there is local spinal tenderness. Pain on spinal percussion. Angular kyphosis. Thoracic or abdominal radicular pain may wrongly divert attention to the chest or abdomen, and in elderly there may not be convincing H/O injury; any suspicion merits radiography.

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AP and lateral views primarily. In seriously injured patient there may be difficulty in lateral view, a

shoot through lateral may be taken. If these are unsatisfactory, personally supervise the turning of patient while taking lateral view. Take care that upper part of spine with shoulders are turned together with pelvis and that patient remains well supported when he is on his side.

# of Thoracic & Lumbar spine Most important decision to make in any spinal injury is whether it is stable or not, because this profoundly influences the treatment. Most stable # are uncomplicated by damage to cord or cauda equina, although bursting, compression # are an occasional exception. Unstable # may be accompanied by neurological involvement. If neurological involvement is incomplete, there is always hope of recovery. There is a risk that further displacement at # site may jeopardize this, or convert an uncomplicated injury to a complicated one. Treatment is vitally important. Commonest spinal injury is wedge compression #. Most common problem is to recognize a wedge # and decide whether it is stable. Other types of injury are most often unstable. Thoracic/Lumbar Stable wedge # Wedge # are commonly diagnosed on lateral views and caused by pure flexion forces. Check for difference in height between anterior and posterior margins of vertebral body.

Less commonly, when there is rotational element added to forward flexion, vertebral wedging may

be apparent in AP view. This form of wedging is often associated with root compression on narrowed side, and these injuries have poorer prognosis regarding ultimate functional recovery and freedom from pain. Interpreting radiographs
In thoracic spine, anterior wedge # of single vertebra will lead to localized kinking with or without

gibbous. Multiple # in thoracic spine, especially when wedging is slight in each of affected vertebra, will lead to more regular kyphosis. In either circumstances, increased thoracic curvature will produce increased lumbar lordosis and/or hyperextension in hip joint. In lumbar spine, anterior wedge # lead to obliteration or reversal of normal lumbar lordosis.

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Anterior border of vertebra will measure less than posterior. Crushing of anterior portion may be

regular, or result in a marginal shearing # (generally anterior superior corner). If posterior margin is decreased relative to vertebrae above and below, it is evidence of increased violence, and possibility of bony fragments encroaching in vertebral canal is there.

Assess the amount of wedging, # is likely to be stable if height of anterior margin still amounts to
2/3rd or more of posterior or if degree of wedging is 15 or less, or if width of body divided by 15 difference in heights is greater than 3.75.

For upper eight thoracic vertebrae, look for any associated # of sternum. Each of these vertebrae is
linked by ribs to the sternum, and appreciable wedging cannot occur without involvement of these structures (sternum or ribs).

Unstable # Marked wedging (20 or more, or collapse of anterior margin to less than half the posterior) denotes (20 instability (as it is associated with PLC rupture). If posterior margin is reduced in height a greater

21 degree of wedging is possible without PLC rupture. Posterior lumbar bulging is less serious than in dorsal spine because in dorsal spine the canal is narrow.

Look for other evidence of damage to PLC and associated structures responsible for spinal

stability. Especially look for avulsion # of spinous process, avulsion # of tip of spinous process or wide separation of vertebral spines at the level of injury.

Examine carefully for # at level of facet joints or pedicles. A comminuted # of vertebral body with
involvement of these structures i.e. facet joint # is generally unstable; bilateral pedicle # are invariably unstable.

Look for shift of one vertebra relative to another. This is invariably a sign of instability. Vertebral

displacement patterns include ruptured PLC with unilateral facet joint displacement, in lateral view, degree of forward shift about 1/3rd or less and bilateral dislocated facet joints, often with body # and greater degree of displacement.

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There may be shearing # of vertebral body, bilateral neural arch # and traumatic spondylolisthesis.

In all these injuries there is damage to PLC. If there is any remaining doubt take oblique view and supervised lateral view in slight flexion. If available CT scan of affected part provide useful information.

X-ray of spine give unequivocal evidence of instability. Where there is slightest suspicion of PLC
involved, that structure must carefully be examined clinically. Press firmly between successive spines, preferably in slight flexion. If ISL are torn, the examining finger will encounter a boggy softness instead of normal resistance to pressure.

Treatment Stable # Admit for complete bed rest in recumbency with one pillow. Analgesics SOS. When acute symptoms have settled, extension exercises started and vigorously practiced. Patient can be allowed up and home at 6 weeks. This programme may be shortened if wedging is minimal.

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Treatment of unstable #
No or incomplete neurological lesion : Aims of treatment are to reduce displacement that is present,

prevent any recurrence of displacement with risk of neurological disasters until stability is regained. Stability is achieved by spontaneous anterior fusion, healing of torn PLC (very uncertain and unreliable) or by surgical fusion. Reduction by gently extending the spine with a pillow or sandbag at level of injury. If unsuccessful or if facets are locked, OR is required. After reduction, further care is dependant on nature of injury and availability of equipments.

Treatment of unstable # Spine may be fixed internally during OR. Paired Meurig-Williams plates are secured with set screws passed through spinous processes above and below level of #. Nuts are keyed into plates. This form of fixation almost invariably cuts out and can only be relied on for about 4 weeks.

Plaster jacket applied with spine in extension. Sedated but conscious patient supports himself by

thighs and shoulders between 2 tables while plaster is applied. Stockingette with felt and wool pads to protect bony prominences is applied prior to encircling plaster bandages and slabs. Patient is lifted on to pillows and plaster trimmed when dry.

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Surgery in form of fusion is indicated if there is evidence of recurrence of displacement after

conservative treatment, if rupture of PLC is main element of injury. Posterior fusion is generally employed using bone grafts from ileum wired to spinous process above and below the injury. Spinous processes and laminae are rawed and bone chips are also packed into the area. After fusion, patient may be nursed in Stryker frame or plaster bed with anterior and posterior turning shells for 6-8 weeks. Plaster bed is contraindicated in paraplegia. Treatment of unstable # With complete, irrecoverable cord lesions : If spine is grossly unstable, IF may be indicated to facilitate nursing, to reduce chronic back pain from local root involvement, to prevent mal union and degree of spinal deformity which would make sitting and rehabilitation difficult. If spine is not wildly unstable, and first class nursing is available, there is less need for IF and treatment is then of accompanying paraplegia. Retro spondylolisthesis At TL junction result from blow in sacral or lower lumbar region. There may be shearing through disc, vertebral body or the pedicles leading to impingement of articular processes on vertebral body.

Neurological involvement if present is seldom complete. PLC is damaged. Treat it as unstable injury unless there is strong contrary evidence. Lumbar transverse process may be # by avulsion of quadratus lumborum, direct trauma or

Transverse process #

rotational injuries of spine. Symptomatic treatment with analgesics and bed rest is needed. If multiple # are present there may be substantial retroperitoneal hemorrhage leading to shock and paralytic ileus or underlying renal damage. These are treated along routine lines. Neurological assessment Testing for evidence of muscle activity and its power in all muscle group below the level of injury. Testing sensation to pin prick, light touch and proprioception over entire area affected. Testing reflexes - DTR, plantar, anal and glansbulbar reflex.

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If findings indicate complete spinal lesion, examination should be repeated after 6, 12 and 24

hours.

Common lesions Spinal concussion leads to temporary arrest of conduction, effects are patchy and recovery is rapid. If there is complete spinal lesion on first examination, spinal concussion is an unlikely but possible cause. If after 12 hours the lesion remains complete, spinal concussion is not the cause. If there is any evidence of voluntary motor activity, skin sensation or proprioception below the level of injury, cord has not been transacted and further recovery is possible. After an injury to cord, reflexes generally disappear for at least some hours, and sometimes as long as 2 weeks. Return of reflexes with continued absence of all sensations and voluntary muscle contraction confirms a transaction of cord. Common lesions Where the injury is at a level where there is potential damage to lumbar nerve roots or cauda equina e.g. injuries at TL junction, persistent absence of reflexes would confirm such damage. Cord transaction is irrecoverable, but there is potential recovery where there is involvement of nerve roots and the cauda equina. Neurological lesions in spinal injuries Spinal cord ends at L1, any injury distal to this can involve the cauda but not the cord. All lumbar and sacral segments of cord lie between D10 and L1 only. Injuries at TL junction produce great variety of neurological disturbances like cord may or may not be transected, nerve roots may be undamaged , partly divided or completely divided.

Myotomes As a rule, motion in each joint is logically controlled by 4 segments. Extension Flexion Hip : L2,3 L4,5 Knee : L3,4 L5, S1 Ankle : L4,5 S1,2 In addition, inversion is controlled by L4 and eversion by L5,S1.

26 Myotomes

In UL, the arrangement is less regular. Shoulder :AbductionC5, AdductionC6,7 :Abduction Adduction Elbow : Flexion-C5,6(B),Extension-C7,8(T) Wrist Flexion and extension C6,7 Finger flexion and extension C7,8 Pronation and supination C6 (S) Hand intrinsic muscles T1

Dermatomes Lumbar and sacral dermatomes have a complex arrangement. Outer border of foot is S1. Medial part of foot and lateral part of leg by L5. Stocking top area is L2. Saddle area is S3.

Dermatomes In UL, anterior axial line follows the line of 2nd rib from angle of Louis and continues down anterior aspect of arm, splitting near midline finger which is supplied by C7. the other dermatomes are arranged in a regular fashion on either side of axial line.

27 Cervical cord special features Phrenic N arises from C4, with minor contribution from C3 & C5. Cord section proximal to phrenic N will lead to rapid death from respiratory paralysis. Those with lesions at C4-5, and distal are capable of respiration without external support. C2 and C3 supply vertex and occiput accounting for pain there in upper cervical lesions. C5-T1 contribute to brachial plexus.

Neurological control of bladder Autonomic fibers controlling detrusor muscle of bladder and IS travel from cord segments S2,3 to bladder via cauda equina. Under normal circumstances bladder sensation and voluntary emptying are mediated through pathways stretching between the brain and sacral centre.

Neurological control of bladder If cord is transected above S2,3 segments e.g. by thoracic spine #, voluntary control is lost, but potential for coordinated contraction of bladder wall, relaxation of IS and complete emptying remains. Normally 200-400 ml of urine is passed every 2-4 hours, reflex activity being triggered by rising bladder pressure or skin stimulation. This is called automatic bladder or cord bladder.

Neurological control of bladder Injuries which damage the sacral centers or the cauda prevent coordinated reflex control of bladder activity. Bladder emptying is always incomplete and irregular, and occurs only as a result of

28 distention. Its efficiency varies with the patients state of health, the presence of urinary infection patient and muscle spasms. (Autonomous or isolated atonic bladder).

Treatment of spinal paralysis

Aim of treatment is maximal physical recovery, complete physical independence and return of full

time employment. These ideals are most fully realized in special resources and environment of paraplegic unit, so patient referred to such unit at the earliest. Pending transfer, and assuming injury has been dealt with, it is vital that attention is paid to problems of skin and bladder. Skin If pressure is applied to skin, it becomes ischemic; if pressure is maintained, necrosis from tissue anoxia results. Skin of elderly is thin, and least able to tolerate pressure. Poorly nourished skin, anemia, and local skin damage such as abrasion effect adversely. Most important are duration of ischemia and amount of pressure applied. Duration of pressure Minimized by regular turning of patient. During initial weeks, see that patient does not lie for longer than 2 hours in one position. If patient is nursed on Stryker's frame, alternates from prone to supine. If nursed on bed, he alternates between lying on each side and supine position. Regular turning of patient should start from time of injury; irreversible damage may be done on the day of admission when other problems allow this vital aspect of treatment to be overlooked for some hours. Amount of pressure If body weight is locally concentrated, then ischemia will be complete. If skin loading is reduced by spread over a large area, then ischemia will be less severe and more tolerable. For this reason, pressure sores tend to start over bony prominences so particular attention should be paid to these areas by local padding. To distribute body weight more evenly, patient may be nursed on pillows laid across the bed from head to foot. Amount of pressure When patient is lying on his back, additional pillows laid horizontally may be used to support elbows and arms. Pillows may also be placed under the legs so that heels are relieved of pressure. When patient is lying on side, pillow may be placed between the legs and legs positioned in such a way that the malleoli and knees are free from pressure. In some centers, water bed or sand beds are used to help distribute the loads on the skin. Skin Important to preserve tone and general condition of skin. If it becomes moist, it becomes susceptible to infection. If it is subjected to friction through contact with rough unyielding surfaces, local abrasion occurs. Local injury of this nature increases tissue demands and initiate production of pressure sores. Skin To prevent this, un starched, soft bed linen should be used and non porous surfaces avoided. Nursing the patient on sheep skin sometimes advocated. Skin should be protected from incontinence. Skin hygiene maintained by frequent thorough cleansing with soap and water. After washing, skin must be thoroughly dried, rubbing with alcohol which helps drying and at the same time lead to temporary local vasodilatation. Talcum powder helps drying and reduce friction between skin and bed linen.

29 Skin If pressure sores occur, preventive measures should be tightened up, and any underlying anemia corrected. Any local sloughs or sequestrum should be removed. If area involved is small, healing may be achieved with local dressings leading to granulation and contraction. If large area is involved, rotational flaps usually afford best means of closure. If sores persist, are frequently F/B progressive anemia, deterioration in general health and well being. Bladder Effects of spinal paralysis on bladder are dependant on level of injury. Immediate problem is prevention of over distention while minimizing the risks of infection. Methods available are intermittent SPC using plastic tubing, this carries risk of pelvic infection. Intermittent catheterization if properly performed with full aseptic precautions carries low risk of infection but it is very demanding on staff. Indwelling catheterization is commonest method employed, but almost invariably accompanied by UTI. Bladder Mechanical emptying of bladder by one of these methods is usually required for 3-4 weeks, after which, in appropriate lesions automatic function will start to take over. This is assessed by removing the catheter, giving copious fluids, when filling of bladder is apparent, trying to achieve emptying by stroking the skin in inner groin area or by applying manual pressure over bladder. Bladder If these measures fail, re catheterization is necessary and procedure repeated after a week. Thereafter the efficiency of emptying should be assessed by measuring residual urine every 3-6 months. Renal function should be reviewed by yearly IVP, urine C/S and SU. Failure to establish a satisfactory emptying pattern will require skilled urological investigation and management. Physiotherapy and occupational therapy Commenced without delay. Chest : Risks and effects of respiratory infections should be minimized by deep breathing exercises, the development of accessory muscle of respiration, assisted coughing, percussion and postural drainage. Joints : Mobility should be preserved in paralyzed joints by passive movements. Done with caution if there is any spasticity, overstretching must be avoided to minimize the risk of myositis ossificans. Physiotherapy and occupational therapy Un paralyzed muscles : Should be developed for compensatory use. For e.g. shoulder girdle exercises to make unaided bed-wheelchair transfers possible. Troublesome muscle spasms may be controlled with diazepam. Physiotherapy and occupational therapy Depending on the level of the lesion the patient may require assistance in some or all of following areas :Regaining balance for sitting or standing. Tuition in caliper walking or gait improvement in partial lesions. Overcoming problems of dressing. Help with alterations and adjustments in home to permit wheelchair use. Industrial retraining or other measures to help return to employment.