n Spine anatomy Xray Cervical spine n Thoracic

Normal lordosis < 60° slop of sacral base = 45° from horizon

L spine X-ray Oblique view Scotty dog sign 3 1 2 4 5 6

The stability n n n Anterior column injury → stable Anterior & middle column

$C 2 tear drop fracture stable$

$Hangman fracture Unstable$

$Wedge fracture Unstable$

$Tear drop fracture$

C 4 -C 5 Bilateral facet dislocation Unstable

C 5 C 6 bilateral facet subluxation Unstable

Atlantodental interval Atlanto-axial instability Unstable

Occipitoatlantal articulation Power ratio

$90 % of spine fractures$

Effects on spine‘s functions 1. 2. 3. 4. Stability Posture Neural protection Neurological function

1 - Stability More columns damage → more instability

$2 - Posture and deformity n n n Pain Imbalance at the fracture site$

3 - Neural protection Spinal deformity ↓ spinal canal stenosis ↓ Varying degree of

Neural structures occupies 50% spinal canal volume

4 - neural function n n Nerve lesion Cord lesion

Nerve lesion (Overstretched–crushed–severed) nerve structures ↓ Irreversible Chance for recovery : Partial lesion n

Cord lesion Drug may give a chance MPS ( corticosteroid ) Reduce necrosis /

$T vertebra Burst fracture$

$L 2 burst fracture$

$L 3 burst fracture with rotation$

$2 T 8 burst fracture + T 9 wedge fracture 8$

Causes of spinal column and spinal cord injury

Trauma patient n n The A – B – C – D RESUSCITATION (

Trauma patient - accident scene n n n A : airways B : breathing

Trauma patient - Transfer Scoop-style stretcher

Trauma patient - Resuscitation Blood pressure BP > 85 mm Hg → better neurogenic

Neurogenic shock n 3 vital signs indicates above T 6 injury : Hypotension n

Low blood pressure. . !? ↓ BP + bradycardia =Neurogenic shock ↓ BP +

Trauma patient - Resuscitation How to deal with Neurogenic shock : n volume replacement

Trauma patient - Assessment Physical examination : n Head n n n n lacerations

Neurologic evaluation n Level of conscious : n Glasgow coma scale Eyes open n

the nipple line (T 4) xiphoid process (T 7) umbilicus (T 10) Dermatomes inguinal

Reflexes Stretch reflexes: n Spinal shock = absent n Upper motor neuron lesion =

Reflexes n Planter reflex : Babinski’s sign n Oppenheim’s sign n n Cremasteric reflex

Lesion level The most caudal segment with both sensory and motor function bilaterally

Complete / incomplete cord lesion? n n Complete : no motor/sensory function exist more

Classification Central cord syn. Anterior cord syn. Posterior cord syn. Brown-Sequal syn.

Sacral sparing Continued function in the conus medularis = incomplete cord injury Assessment :

Spinal shock n n n After severe spinal cord injury A state of complete

Spinal shock n After injury : n No evidence of spinal function below the

Roentgenogram n Plain Xray : Routinely n Chest n Pelvis n Cervical spine <AP/Lateral>

ER intervention n High dose intravenous methylprednisolone Within 8 hours = more significant improvement

ER intervention n Osmotic diuretics Manitol n Low molecular weight dextran n Used in

ER intervention n Cervical stabilization : Bilateral sand bag + taping n Philadelphia collar

Thoraco-lumbar braces n n Jewett brace Custom-molded TLSO

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n Spine anatomy * X-ray Cervical spine n Thoracic spine n Lumbar spine n n Spine trauma Cervical spine n Thoracic & lumbar spine n n Trauma patient with spine lesion

Cervical spine

Spine Anatomy

Anatomy

Anatomy 3 2 1 4

Cervical spine X-ray

C spine X-ray Lateral view 5 4 6 1

C spine X-ray Lateral view

C spine X-ray AP view 2 1

C spine X-ray AP view

C spine X-ray Oblique view

C spine X-ray OMO view 1 2 2 3

C spine X-ray OMO view

Thoracic spine

Spine Anatomy

Anatomy

Normal kyphosis 15° - 50°

Anatomy

T spine X-ray

T spine X-ray AP view 1 2 3

T spine X-ray AP view

T spine X-ray lateral view

Lumbar spine

Spine Anatomy

Anatomy

Normal lordosis < 60° slop of sacral base = 45° from horizon

L spine X-ray

L spine X-ray AP view

L spine X-ray AP view 1 4 2 3

L spine X-ray Lateral view

L spine X-ray Oblique view Scotty dog sign 3 1 2 4 5 6

L spine X-ray Oblique view Scotty dog

L spine X-ray Oblique view

C spine trauma

Denis’ three column model of the spine

The stability n n n Anterior column injury → stable Anterior & middle column injury→more unstable 3 column injury → unstable

$C 2 tear drop fracture stable$

C 2 tear drop fracture stable

$Hangman fracture Unstable$

Hangman fracture Unstable

$Wedge fracture Unstable$

Wedge fracture Unstable

$Tear drop fracture$

Tear drop fracture

C 5 -C 6 Bilateral facet dislocation

C 4 -C 5 Bilateral facet dislocation Unstable

Unlateral facet dislocation Unstable

C 5 C 6 bilateral facet subluxation Unstable

Atlantodental interval Atlanto-axial instability Unstable

Occipitoatlantal articulation Power ratio

T+ L spine trauma

$90 % of spine fractures$

90 % of spine fractures

Effects on spine‘s functions 1. 2. 3. 4. Stability Posture Neural protection Neurological function

Denis’ three column model of the spine

1 - Stability More columns damage → more instability

2 - Posture and deformity

$2 - Posture and deformity n n n Pain Imbalance at the fracture site$

2 - Posture and deformity n n n Pain Imbalance at the fracture site Compensatory curves

3 - Neural protection Spinal deformity ↓ spinal canal stenosis ↓ Varying degree of compression

Neural structures occupies 50% spinal canal volume

4 - neural function n n Nerve lesion Cord lesion

Nerve lesion (Overstretched–crushed–severed) nerve structures ↓ Irreversible Chance for recovery : Partial lesion n Release within 8 hours n

Cord lesion Drug may give a chance MPS ( corticosteroid ) Reduce necrosis / oedema n In the first 8 hours n n Regimen : 30 mg/kg/15 minutes After 45 minute 5. 4 mg/kg/hour for 23 hour

Lesion classification

$T vertebra Burst fracture$

T vertebra Burst fracture

$L 2 burst fracture$

L 2 burst fracture

$L 3 burst fracture with rotation$

L 3 burst fracture with rotation

$2 T 8 burst fracture + T 9 wedge fracture 8$

2 T 8 burst fracture + T 9 wedge fracture 8

Trauma patient with spine lesion

Causes of spinal column and spinal cord injury

Trauma patient n n The A – B – C – D RESUSCITATION ( BP ) Conscious level ( Glasgow coma scale ) Assessment of injuries ( Determine the PRIORITY )

Trauma patient - accident scene n n n A : airways B : breathing C : circulation & cervical spine D : disability – drugs E : exposure ( undress the patient ) Spinal column injury must be suspected in in all polytrauma patients, especially < intoxicated – unconscious > individuals.

Trauma patient - Transfer Scoop-style stretcher

Trauma patient Transfer

Trauma patient - Resuscitation Blood pressure BP > 85 mm Hg → better neurogenic outcome

Neurogenic shock n 3 vital signs indicates above T 6 injury : Hypotension n Hypothermia n Bradycardia n Disruption of sympathetic outflow. T 1 -L 2 ↓ unopposed vagal tone

Low blood pressure. . !? ↓ BP + bradycardia =Neurogenic shock ↓ BP + tachycardia = blood loss occult intra-abdominal injuries

Trauma patient - Resuscitation How to deal with Neurogenic shock : n volume replacement n vasopressors And of course<Treat other injuries>

Trauma patient - Assessment Physical examination : n Head n n n n lacerations Contusions Facial fractures ear canal - nasal leakage ( CSF – blood ) Spinous processes palpation Bowel / bladder incontinence Penile erection Occult injury ( abdomen – chest – extremities )

Neurologic evaluation n Level of conscious : n Glasgow coma scale Eyes open n Best verbal response n Best movement response n

Sensory examination

the nipple line (T 4) xiphoid process (T 7) umbilicus (T 10) Dermatomes inguinal region (T 12, L 1) The perineum and perianal region (S 2, S 3, S 4)

Motor examination

Reflexes Stretch reflexes: n Spinal shock = absent n Upper motor neuron lesion = hyperreflexia + spasticity + clonus n Lower motor neuron lesion = absent

Reflexes n Planter reflex : Babinski’s sign n Oppenheim’s sign n n Cremasteric reflex T 12 -L 1

Lesion level The most caudal segment with both sensory and motor function bilaterally

Complete / incomplete cord lesion? n n Complete : no motor/sensory function exist more than 3 segments below the site of injury. Incomplete : some neurologic function below it.

Just to remember !

Classification Central cord syn. Anterior cord syn. Posterior cord syn. Brown-Sequal syn.

Sacral sparing Continued function in the conus medularis = incomplete cord injury Assessment : n Perianal sensation n Toe flexion n Rectal sphincter

Spinal shock n n n After severe spinal cord injury A state of complete spinal Areflexia. Last for varying length of time. 99% within 24 hour. n Evaluation by : Testing the bulbocavernosus reflex ( S 3 – S 4 ) n Anal wink reflex n

Bulbocavernosus reflex Anal wink

Spinal shock n After injury : n No evidence of spinal function below the level of injury ( even bulbocavernosus reflex ) → no determination of completeness of injury n Return of bulbocavernosus reflex with no sacral sparing signs → complete lesion

Roentgenogram n Plain Xray : Routinely n Chest n Pelvis n Cervical spine <AP/Lateral> Poly trauma n <AP/Lateral> thoraco-lumbar spine film n n CT MRI

ER intervention n High dose intravenous methylprednisolone Within 8 hours = more significant improvement 30 mg/kg in 15 minutes → after 45 minutes → 5. 4 mg/kg/hr in the remained 23 hour Complications : Wound infection GI Haemorrhage

ER intervention n Osmotic diuretics Manitol n Low molecular weight dextran n Used in head trauma No clinical effectiveness in spinal cord injury

ER intervention n Cervical stabilization : Bilateral sand bag + taping n Philadelphia collar n Traction : n Gardner wells n Halo vest n

Taping

Philadelphia collar

Gardner-wells tongs

Halo vest orthosis

Thoraco-lumbar braces n n Jewett brace Custom-molded TLSO

Jewett brace

Full contact braces