Spinal Trauma

Oleh :
Winda Arista Haeriyoko

Pembimbing :
dr. Komang Arimbawa, Sp. S
 Outline
• Insiden
• Tipe cedera
• Gejala klinis
• Gambaran radiologi
• Syok spinal
• Tatalaksana
 Incidence
• 10 - 15 per million
• 18 - 35 years
• Male - 3:1
• Domestic 16%
• Industrial 11%
• Sports 16% - diving incidents
• Self harm 5%
 Types
• Cervical 40%
• Thoracic 10%
• Lumbar 3%
• Dorso lumbar 35%
• Lainnya 14%
 Anatomy
• Korda spinalis berakhir di bawah batas bawah dari L1
• Regio ini disebut Cauda equina yang terletak d bwh
L1
• Ruang mid dorsal spinal cord & neural canal space
memiliki diameter sama shg memungkinkan terjadi
lesi komplit
• Mechanical injury  early ischaemia  cord edema
 cord necrosis
• Neurological recovery tdk dpt diprediksi pd cauda
equina ie. peripheral nerves
 Cervical spine anatomy
• Anterior column - Anterior longitudinal ligament+
Anterior annular ligament and anterior half of VB.

• Middle column – Posterior long. Lig. + Posterior

annular ligament +Posterior half of VB.

• Posterior Column – Lig flavum + superior &

Interspinous lig + intertransverse capsular lig + neural
arch + pedicle & spinous process.
 Significance
• Unstable jk middle column + Anterior or Posterior
column rusak

• Ruptur pd interspinous ligament akan terjadi:

- Associated dgn avulsion of spinous process
- Unstable spine
- Further flexion meningkatkan neurological injury
 Level of Spinal injury
• Menentukan level defisit neurologis dgn cara
segemen terendah dgn fungsi motorik & sensorik
normal

• Sulit ditentukan karena beberapa kondisi:

- Kebanyakan muscle efferents menerima fibres lebih
dari satu level
- Closed cord lesions may extend over several cms.
- Dermatomes have imprecise boundaries.
 Cord level
• C2 – C7 = add +1 for cord level

• T1 – T6 = add +2
• T7 – T9 = add +3

• T10 = L1, L2 level

• T11 = L3, L4 level

• L1 = sacro coccygeal segments

 Degrees of injury
• Complete - flaccid paralysis + total loss of sensory &
motor functions

• Incomplete - mixed loss

- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome
 Anterior spinal cord syndrome
• Flexion rotational force to spine

• Due to compression fracture of vertebral body or

anterior dislocation

• Anterior spinal artery compression

• Loss of power, reduced pain and temperature below

the lesion.
 Posterior cord syndrome
• Hyperextension injuries

• Posterior vertebral body fracture

• Loss of proprioception and vibration sense

• Severe ataxia
 Central cord syndrome
• Older age with cervical spondylosis
• Hyperextension with minor trauma

• Cord is compressed by osteophytes from vertebral

body against thick ligamentum flavum.

• Damages the central cervical tract

• UMN lesion to legs (spastic)

• LMN to arms (flaccid paralysis)
 Brown sequards syndrome
• Hemisection of the cord

• Stab injury and lateral mass fractures

• Uninjured side has good power but absent pinprick

and temperature.

• Spinothalamic tracts cross to opposite side of the cord

three segments below.
 Types of bony injury
• Flexion

• Extension

• Flexion with rotation

• Compression
 Pathophysiology

• Primary Neurological damage

Direct trauma, haematoma & SCIWORA < 8yrs old
In 4hrs - Infarction of white matter occurs
In 8hrs - Infarction of grey matter and irreversible paralysis

• Secondary damage
Hypoxia
Hypoperfusion
Neurogenic shock
Spinal shock
 Hypoxia
• Lesions above C5 – damage to diaphragm leads to 20%
reduction in vital capacity Rx Phrenic n. pacing

• Lesions at D4-6 – reduces vital capacity if < 500ml patient is

ventilated

• Intercostal nerve paralysis

• Atelectasis – poor cough

• V/Q mismatch
• Reduced compliance of lung – muscle fatigue.
 Neurogenic shock
• Lesions above D6
• Minutes – hours (fall of catecholamines may take 24 hrs)
• Disruption of sympathetic outflow from D1 - L2
• Unapposed vagal tone
• Peripheral vasodilatation
• Hypotension, Bradycardia & Hypothermia

• BUT consider haemmorhagic shock if – injury below D6,

other major injuries, hypotension with spinal fracture alone
without neurological injury.
 Spinal shock
• Transient physiological reflex depression of cord function –
‘concussion of spinal cord’

• Loss anal tone, reflexes, autonomic control within 24-72hr

• Flaccid paralysis bladder & bowel and sustained Priapism

• Lasts even days till reflex neural arcs below the level recovers.
 Assessment & Managemnt
• Failure to suspect leads to failure to detect injuries
• ABCDE – Logroll and remove the spinal board
• Look for markers of spinal injury
• Secondary survey
• Adequate Xray’s
• Emergency treatment
• Surgery
• Definitive care & rehab.
 Clinical features
• Pain in the neck or back radiating due to nerve root
irritation

• Sensory disturbance distal to neurological level

• Weakness or flaccid paralysis below the level

 Signs in an Unconcious patients
• Diaphragmatic breathing
• Neurological shock (Low BP & HR)
• Spinal shock - Flaccid areflexia
• Flexed upper limbs (loss of extensor innervation
below C5)
• Responds to pain above the clavicle only
• Priapism – may be incomplete.
 Signs of spinal injury
• Forehead wounds – think of hyperextension injury

• Localized bruise

• Deformities of spine - Gibbus, feel a step & Priapism

• Beevors sign – tensing the abdomen umbilicus moves

upwards in D10 lesions
 Prehospital transfer
• Awareness of the crew & by A&E staff
• Modified left lateral position at scene
• Kendrick or Russell’s extrication device
• Scoop stretcher slotted together around the patient
• Agitated patient left alone with hard collar
• Repeated assessment enroute
• Head down if they vomit
• Remove objects from clothes to avoid pressure sores
• Avoid opiates in high lesions
• Avoid oral suction in tetraplegics – vagal reflex
 Care in A&E
• Careful manual handling especially if unconcious
• Jaw thrust is safer
• Correct gross spinal deformities
• Call the anaesthetist if diaphragmatic paralysis or RR>35
• Use flexible fibreoptic scopes in unstable fractures
• Ryles tube if abdominal distension causes respiratory probl
• Cathetrize to avoid overstretching of detrusor
• IV fluids – paralytic ileus in first 48hrs.
• Passive movements to rule out fractures
• Small iv doses of opiates
 Assessment
• Document the level of injury

• Rule out other injuries – DPL in abdominal injuries as there is

paralytic ileus and absent peritioneal irritation.

• Associated injuries in dorsal spine fracture are :

- Renal injuries
- Chest and Sternal injuries
- Wide Mediatinum due to fracture haematoma.
- Retroperitoneal injuries
 Radiology
• Be thorough – Adequacy, Alignment,Bones, Cartilages and
soft tissues and distances
• SCIWORA in kids

• Low threshold for xray in rheumatoid & Ankylosing spond

• Flexion injury common in lower cervical spine

• Extension injury in upper cervical Spine

• Junction of mobile & fixed part are prone to injury eg. C7

T1 & D12 L1.
 Radiographs in spinal injuries
• Lateral C spine views in diagnostic in 80%

• Complete set of C spine xray are 90% diagnostic

• CT of the c spine is 98% diagnostic

• 22.5* logrolled view for better views of the facets

• 45* view shows the intervertebral foramen & facets

 Normal Cervical Spine
• Peg & lateral mass distance <2mm and symmetrical
• Peg & arch of atlas distance <2mm in adults < 4mm in kids

• Above C4 the width is <half of the VB width below C4 its

equal to one VB width

• Pseudosubluxation of C2 on C3 is normal in young kids& it

disappears on extension
• C1 and C2 interspinous space <10mm wide

• Distance between occiput and atlas <5mm

• Anterior compression of VB >40% suggest burst fracture
 Abnormal C spine
• Unilateral facet dislocation < half of the vertebral body
shifted on the lateral view
• Bilateral facet dislocation > half shifted forwards

• Wide interspinous gap is unstable (crush fracture or

subluxation) suggestive of rupture of the posterior cervical
ligament rupture and haematoma formation.

• Severe flexion injury – fractures the anteroinferior margin

of the vertebral body
• Severe extension injury – fractures the anterosuperior
margin of the VB.
 Emergency treatment
• ABCDE
• Keep warm
• Treat if BP<80mmHg & HR <50bpm
• Spring loaded gardener wells calipers for traction
• H2 Antagonists & Heparin

• Methylprednisolone 30mg/kg iv bolus over 15min

immediately
• 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.
 Whiplash injury
• Sudden hyperextension and flexion
• Increasing neck pain for the first 24hours
• Associated headache, pain radiating to both shoulders and
paraesthesia in hands
• Reduced lateral flexion
• Anterior longitudinal ligaments are torn causes dysphagia
• Forward flexion against resistance is painful
• 90% are asymptomatic after 2years
• 10% still have pain
• Some still claim money hence the need for proper
documentations.