Spinal injuries

20 رجب 1434هـsurgery lec. By Dr .Zaid Shammaa

30/5/2013 م

Spinal injuries

Acute injuries of spine and spinal cord are among the most common cause of death and disability.
For this reason,evaluation plus treatment of trauma is required for preservation of spinal cord and nerve root function,and restoration of alignment and stability.

Epidemiology:

Spinal injuries tend to occur in young,predominantly in male,mostly by motor vehicle accident.
Spinal injuries tend to occur concomitantly with severe head injury.
Cervical injuries is the most frequently occur by motor traffic accidents.

Etiology:

A) trauma:
1.hyperflexion :this is the most frequent type of injury e.g. fall of heavy object on the trunk or head.
2.hyper-flexion and rotation
3.vertical compression :e.g. fall on the head
4.hyper-extension:uncommon.


B) pathological fracture :
1.metastasis
2.osteoporosis

Types of spinal injuries:

A. according to stability
B. according to morphology
C. according to lesion

A).spinal injuries according to stability:

The spinal stability: is the ability of spine under physiologic loads to limit displacement so as to prevent injury or irritation of spinal cord and nerve roots and to prevent incapacitating deformity or pain due to structural damage.

Radiologically: the most common classification is the three column of Denis which divide the spine into posterior ,middle and anterior.
The posterior column include all of the posterior bony and ligamentous elements while middle column includes posterior longitudinal ligament and all elements comprising the posterior half of vertebral body and intervertebral disc ,anterior column includes the remainin of vertebral body and disc, as well as anterior longitudinal ligament.
Injury of two or three columns are referred as unstable.

B).spinal injuries according to morphology:

1.wedge fracture :caused by hyperflexion
this fracture is stable and the cord is not damaged.
2.fracture dislocation :caused by hyperflexion and rotation ,unstable and damaged cord.
3.dislocation: pure dislocation without fracture is possible in cervical spine because its articular process are rather horizontal.
4.burst fracture(comminuted):it is uncommon ,caused by vertical compression of straight spine .the vertebral body is comminuted but ligaments are intact. The fracture is stable .
5.avulsion of spinous and transverse processes are not accompanied by neurological deficit and no management needed.


C).spinal injuries according to type of lesion:
1. Incomplete lesion: any residual motor or sensory function more than three segments below the level of injury.
2. Complete lesion: no preservation of any residual motor or sensory function more than three segments below the level of injury.
Recovery is zero if injury remain complete after 72 hours.
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Spinal shock:

Its transient loss of all neurological functions below the level of injury lead to flaccid paralysis and a reflexia lasting 1-2 weeks occasionally several months and sometimes permenantly.

Clinical features:

1.pain:
a.local pain due to bone or soft tissue injury b.radicular pain due to n.injury

2.vital sign:

a. bradycardia b.hypotension

3.external features:

wounds, bruises or swelling, tenderness and spasm.

4.motor deficit: partial or complete

motor level:is defined as the most caudal level below injury level with grade III(antigravity) .


5.sensation:absent or decreased or hyperesthesia
sensory level: is defined as the most caudal dermatome with intact sensation.

6.reflexes: absent or normal or increased

absent may indicate spinal shock while increased mean incomplete or older complete injury.
7.sphincters:
urinary or fecal incontinence
loss of bulbo cavernous reflex
Radiology:
1.plain x-ray:
AP view and lateral view for all vertebrae.
open mouth view for atlas vertebra.
2.CT scan of injured vertebrae to dignose fracture
3.MRI for spinal cord injury.

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Management of spinal injuries:
initial management; include:
1. Management in field:
immobilization by back board ,sand bag and rigid cervical collar
ABCDE system of resuscitation.
Brief motor examination.


2. Management in hospital:
Continue immobilization.
Continue resuscitation.
Detailed neurological examination to asses motor and sensory level ,reflexes,sign of autonomic dysfunction.
Radiological examination(as mentioned)
Methylprednisolone: should be given within 8 hours to patient of closed spinal injuries.

Subsequent management of unstable fracture:

decompression of neural elements.
Mobilization of patient as early as possible to prevent atelectasis ,pneumonia ,DVT and bed sore.
Stabilize the spine that is not likely to heal without surgical intervention(spinal instrumentation).

Indication of surgical decompression:

Is in complete neurological injury with persistent spinal cord compression at site of injury (bone pieces ,herniated disc ,epidural hematoma or vertebral misalignment ) .
Management of medical complication following spine injury:
1. Skin care:
Skin should be kept dry and clean,washed dried and powdered.
Patient should be turned every two hours on each side.
Established bed sore should be cleaned ,sloughs should be excised and daily dressing should be done.
Good nutrition is required for good immunity.
2. Bladder care:
Catheter is required to maintain empty bladder.
Stroking the sides of thigh initiate bladder contraction.
In cauda equine lesion ,micturition is initiated by abdominal muscle straining.
Frequent catheterization is required to prevent infection.
Cytometery and cystography is required for high residual bladder ,transurethral resection of bladder neck or sphincterotomy may be required.
3. Bowel training:
Every three days enema.
Mild laxatives are required
Straining is trained to evacuate bowel.


4. Muscle and joints:
Contracture should be prevented by positioning and passive movements of joints.
Tenotomy may be required for correction of contracture.
Paraplegic patient should be trained to move his trunk using his arms, wheel chair crutches and leg braces also needed.