( SPINAL INJURY)

.
(3%
(Trauma), 10% )

,

20%
> 15-30 (5%)

(Motor vehicle accident) 45%
(Fall)
20%
(Violence)
15%
(Sport)
15%
(Miscellaneous)
5%
(Classification)
,
3
1.) (Only Spinal Fracture)
2.) (Only Spinal Cord Injury, Spinal cord injury without radiographic abnormality
SCIWORA)
3.) (Spinal Fracture & Spinal Cord Injury)

(Cervical level)

(Compression)(Distraction)
1.)(Hyperextension fracture-dislocation)
Posterior fracture dislocation of dens
Traumatic spondylolisthesis of the axis(Hangman s fracture)
Hyperextension sprain with fracture
Hyperextension fracture-dislocation with fractured articular pillar
Hyperextension fracture-dislocation with comminution of the vertebral arch
2.)(Hyperflexion fracture-dislocation)
Anterior fracture dislocation of dens
1

Hyperflexion sprain:rare
Locked articular facets with fracture
Teardrop fracture-dislocation
2 (C1-2),(C3-7)
( Upper c-spine injury:C1,2)
Atlantoaxial dislocation
Occipital condyle fracture
Atlas fracture:Jefferson Burst fracture
Combinded C1-2 fracture
Axis Odontoid fracture
Hangman fracture
Miscellaneous axis fracture
(Lower c-spine injury:C3-7) 8 (Allen et.al)

Major loading force Action alone

Flexion
Uni or bilateral
Facet dislocation

Extension

Neutral position

With compression
With distraction
Teardrop fracture
Torn post.lig.
ant.body kyphosis
Dislocate or locked facet
Interspinous lig.disruption

Fracture spinous process Fracture facet

Burst fracture

Torn ALL with retrolisthesis

of Superior or inferior VB
Complete lig.disruption
(unstable)

,-(Thoracolumbar level)
Compression,Flexion,Chance(Seat-belt),Fracture-dislocation
(Lumbar level)
Compression,Burst,Chance(Seat-belt),Fracture-dislocation
(Sacral level) Schmidek andassociates
1.)Direct injury : Penetrating ,Low- transverse fracture(S3 and below)
2.)Indirect injury : High transverse fracture(S1,2),Lumbosacral fracture
dislocation,lateral mass fracture,juxtaarticular fracture,cleaving fracture,avulsion fracture,combination
fracture


(Spinal instability)

(Spinal stability)
White&Panjabi
(Clinical stability)
(Physiologic load),
(Displacement), 3 Column
instability 23 Column
(Biomechanical instability)

Spinal Instability
1.)(Acute instability)
1.1) Overt instability 3 Column,
, (Normal activity)
(Surgical stabilization)(Decompression)
1.2)Limited instability Overt instability Ventral
Dorsal
Orthosis
2.)(Chronic instability)
2.1)Glacial instability (,)
Lumbar Spondylolisthesis (Dynamic
x-ray)
2.2)Dysfunctional segmental motion (Progressive deformity)
glacial instability
Instability(Point system)
InstabilityPoint system,,

Quantitation of acute instability in subaxial cervical,thoracic,lumbar injury(White&Panjabi)

Condition
Point assigned
Loss of integrity of anterior (and middle) column
2
Loss of integrity of posterior column
2
Acute resting translation deformity
2
Acute resting angulation deformity
2
3

Acute dynamic translation deformity exaggeration

Acute dynamic angulation deformity exaggeration
Neural element injury
Acute disk narrowing at level of suspected pathology
Dangerous loading anticipated
Score of 5 points or more implies overt instability
Score of 2-4 implies limited instability

2
2
3
1
1

(Ectoderm)(Neural tube)
3-4 (3)
(Newborn)
31
Cauda equina

(Cervical enlargement 13 .)(Lumbar enlargement 12 .)
,
Conus medullaris
Ligamentum flavum ,Posterior longitudinal ligament
(Meninges) 31)Dura mater
,2)Arachnoid membrane Dura,3)Pia mater
Dura ,ArachnoidPiaSubarachnoid space

Grey mater ,
White mater
(Spinal tract)

(tract)
1.)Dorsal column : (light touch),(vibration),
(Proprioception) Medulla
2.)Spinothalamic tract(Anterolateral tract) : (Pain),(Temperature)
1-2
3.)Corticospinal tract :
80%Latereral corticospinal tract,20%
4

Medial corticospinal tract, ---

(C-T-L-S)

1.)Anterior Posterior Spinal arteryVertebral artery

(Upper cervical)
2.)Radicular artery (Lower cervical)
Vertebral artery ,Posterior intercostal artery ,Lumbar artery ,Lateral sacral artery(Radicular artery of
Adamkiewicz Aorta T10-11) Anterior Posterior
Spinal artery Radicular artery Anterior spinal artery 2/3 ,
Posterior spinal artery 1/3

(Watershed area)-

1.) ,,
2.)
,
Grey matter White matter 4 .
8 .(necrosis)
Gliosis Syringomyelia
1(L1)
1(L1)Cauda equina
(Motor system),(Sensory
system),(Autonomic system), (Reflex)

(Longitudinal localization)
,, (Transverse localization)

1.)(Loss of sensation)
(Level of sensory loss)
2.)(Motor weakness) ,(Paraparesis,Paraplegia)
(Quadriparesis,Quadriplegia)(Hemiparesis,Hemiplegia)

 Upper Motor Neuron lesion(

motor neuron
) (Spasticity),(Hyperreflexia),Babinskis sign
Lower Motor Neuron lesion
(Hypotonia),
3.)(Bowel,Bladder dysfunction)
(Sphincter) (Dyssynergia)
4.) Superficial reflex , Deep tendon reflex ,
Lower motor neurone lesion,Upper motor neurone lesion
5.)(Pain)

(Longitudinal localization)

1.)(Higher C-spine) ,-
(Quadriparesis,Quadriplegia),
(Phrenic nerve 3,4,5)
2.)(Lower C-spine)
Bicep C-5,6,Tricep ,wrist extensor C-7, C-8,T-1
3.)(Thoracic spine ) Sympathetic
(Hypotension),(Bradycardia) Horners syndrome
(Miosis),(Ptosis),(Anhydrosis)( (T1),) ,,
4.)(Lumbar spine) ,(Saddle area),

5.) Cauda equina 1

Lower Motor Neuron (Flaccid paralysis),
(Hyporeflexia),
(Transverse localization)
(Transverse localization)
1. (Complete spinal cord syndrome)
,,
Spinal shock(Total loss of motor,
sensory, autonomic, reflex) (Areflexia),(Paralysis),
(Loss of all sensory function),

Sympathetic , Neurogenic shock

Spinal shock 24 .
Spinal shock
1.Minimal reflex activity 3-4
2.Flexor spasm 6-16
3.Alternate flexor and extensor spasm 4-6
4.Extensor spasm >6
2. (Incomplete spinal cord syndrome)
2.1)Central cord syndrome ,,
, Dermatome (Suspended
sensory loss,Bra or cape like)
2.2)Brown-sequard(Hemisection cord) syndrome ,
, (Hemiparesis),
(Proprioception)

2.3)Anterior cord syndrome 23

(Paraparesis,Quadriparesis),
(Proprioception)
2.4)Posterior cord syndrome

Incomplete cord injury

1.) Proproception
2.)Sacral sparing (Voluntary rectal sphincture contraction)

(Clinical Manifestation)

1.) -,
2.) (Neurological deficit)
3.)Neurogenic shock Shock
4.)Shock (Hypovolemic shock)
5.)Spinal deformity ,Spinal instability
(Neurological assesment)

Frankel scale
7

Grade A or 1 Complete motor and sensory paralysisbelow lesion

Grade B or 2 Complete motor paralysis but some residual sensory perception below lesion
Grade C or 3 Residual motor function,no practical use
Grade D or 4 Useful but subnormal motor function below lesion
Grade E or 5 Normal
ASIA (American Spinal Injury Association )Mortor scoring system
(Motor power grade 1-5) Key muscle 10 2
100
Key Muscle
Segment
Action to test
Deltoid(or biceps)
C5
Shoulder abduction or elbow flexion
Wrist extensor
C6
Cock up wrist
Triceps
C7
Elbow extension
Flexor digitorum profundus
C8
Sqeeze hand
Hand intrinsic
T1
Abduct little finger
Iliopsoas
L2
Flex hip
Quadricep
L3
Straighten knee
Tibialis anterior
L4
Dorsiflex foot
EHL
L5
Dorsiflex big toe
Gastrocnemius
S1
Plantar flex foot
Key sensory landmark
Level
Dermatome
C4
Shoulder
C6
Thumb
C7
Middle finger
C8
Little finger
T4
Nipple
T6
Xiphoid
T10
Umbilicus
L3
Patella
L4
Medial maleolus
L5
Great toe
S1
Lateral maleolus
S4-5
Perianal


x-ray film
C 6,7 (Lateral view)
Swimmer view

(Lateral view),

1.)
2.)
3.) ,
4.)
,
(Image): x-ray ,Myelography, CT-scan, MRI
(Management)
.
1.)Transfer :

(Immobilization)Evidence base class 1 ,

2

2.)Resuscitation&Neurological evaluation
(Hypoxia)(Hypotension) Hypovolumic
shock,spinal shock ,,

3.)Spinal Reductiion and Stabilization :

2
1.) (Close reduction &Immobilization)
1.1)(Skull traction:Gardner wells tong,Crutchfield) ( .
5 )(Close reduction)
(Contraindication) :Atlanto-occipital dislocation,Hangman fracture type 2a,3,3
,Skull defect
locked facet (ORIF)
1.2) (Cast, , orthosis :collar,brace)
Upper cervical HALOSOMI brace
9

2.)(Open Reduction Internal Fixation ORIF)

(plate, rod,
screws,wire,cable,cramp)(Spinal fusion,Arthrodesis)
,, Evidence
based class 1 (Standard)
(Option)(Surgical approach&Instrument)
4.)Spinal Decompression : ,
, (ORIF)
5.) : Methyl prednisolone 8
. (Evidence based class 3)
6.) : Paraplegia quadriplegia

1.) : 2
,
2.) (Contracture, Deformity) (Passive
Exercise), splint
3.) neurogenic bladder
6-8 Foleys catheter 7-10
4.) (Malnutrition)
5.) (Deep vein thrombosis) Passive Exercise

6.) Psychotherapy,anxiolytic,antidepressant

1.)
Brown Sequard
Complete Cord
2.)

4 (C4)
Quadriplegia,
C7
Dependent on daily living
C7 ,
Independent
10

- Thoracolumbar : (Full independent)

3. , , ,
, ,

11