11/10/2015

LEARNING OBJECTIVE

To identify Cervical Spine Trauma

To Identify Thoracolumbar Trauma
To Stabilize patient and referral

SPINE FRACTURE

SMF ORTHOPAEDI &

TRAUMATOLOGI
RS PHC / FK UKWM SURABAYA

GOAL OF SPINE TRAUMA CARE SUSPECTED SPINAL INJURY

Protect further injury during evaluation and High speed crash

management Unconscious

Multiple injuries
Identify spine injury or document absence of Neurological deficit
spine injury Spinal pain/tenderness

Optimize conditions for maximal neurologic

recovery

PRE-HOSPITAL MANAGEMENT

Protect spine at all times during the PROTECTION PRIORITY

management of patients with multiple
Detection Secondary
injuries

Up to 15% of spinal injuries have a second

(possibly non adjacent) fracture elsewhere
in the spine Log-rolling

Ideally, whole spine should be immobilized

in neutral position on a firm surface

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PRE-HOSPITAL MANAGEMENT CERVICAL SPINE IMMOBILIZATION

Safe assumptions
Cervical spine immobilization Head injury and unconscious
Multiple trauma
Transportation of spinal cord-injured patients Fall

Severely injured worker

Unstable spinal column
Hard backboard, rigid cervical collar and lateral support (sand
bag)
Neutral position

Philadelphia hard collar

TRANSPORTATION OF SPINAL CORD-INJURED

PATIENTS
CLINICAL ASSESSMENT

Emergency Medical Systems (EMS) Advance Trauma Life Support (ATLS) guidelines
Paramedical staff Primary and secondary surveys

Primary trauma center Adequate airway and ventilation are the most

Spinal injury center important factors

Supplemental oxygenation

Early intubation is critical to limit secondary

injury from hypoxia

PHYSICAL EXAMINATION PHYSICAL EXAMINATION

Inspection and palpation
Information Occiput to Coccyx
Mechanism Soft tissue swelling and bruising
Point of spinal tenderness
energy, energy Gap or Step-off
Spasm of associated muscles
Direction of Impact
Associated Injuries Neurological assessment
Motor, sensation and reflexes
PR

Do not forget the cranial nerve (C0-C1 injury)

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Comparison of neurogenic and hypovolemic shock

NEUROGENIC SHOCK
Temporary loss of autonomic function of the Neurogenic Hypovolemic
cord at the level of injury
results from cervical or high thoracic injury Etiology Loss of sympathetic Loss of blood volume
outflow
Presentation
Flaccid paralysis distal to injury site Blood Hypotension Hypotension
Loss of autonomic function pressure
hypotension Heart rate Bradycardia Tachycardia
vasodilatation
lossof bladder and bowel control Skin Warm Cold
lossof thermoregulation temperature
warm, pink, dry below injury site
bradycardia Urine Normal Low
output 14

DEFINITIONS OF TERMS NEUROLOGIC ASSESSMENT

Neurologic level Spinal shock
Most caudal segment with normal sensory and motor Bulbocavernosus reflex
function both sides
Skeletal level
Radiographic level of greatest vertebral damage Complete VS incomplete cord injury
Complete injury spinal shock
Absence of sensory and motor function in the lowest Sacral sparing
sacral segment Voluntary anal sphincter control
Toe flexor
Incomplete injury
Perianal sensation
Partial preservation of sensory and/or motor function
Anal wink reflex
below the neurologic level

BULBOCAVERNOSUS REFLEX SACRAL SPARING

1. Perianal/perineal sensation
Pull glans or press 2. Rectal tone
clitoris anal 3. Big toe flexion
contraction (int.
sphincter) around Implies partial structural continuity of white
gloved finger matter long tracts
Absence is indicator May be only evidence of incomplete
of spinal shock injuryhigher chance of recovery
Essential to check and document

Skeletal Trauma

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NEUROLOGIC ASSESSMENT

American Spinal Injury Association grade

Grade A E

American Spinal Injury Association score

Motor score (total = 100 points)
Key muscles : 10 muscles
Sensory score (total = 112 points)
Key sensory points : 28 dermatomes

INCOMPLETE CORD INJURY

Anterior cord syndrome

Brown-Sequard syndrome

Central cord syndrome

ANTERIOR CORD SYNDROME BROWN-SEQUARD SYNDROME

Loss of motor, pain and Loss of ipsilateral motor

temperature and propioception

Preserved propioception Loss of contralateral pain

and deep touch and temperature

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CENTRAL CORD SYNDROME CERVICAL SPINE IMAGING OPTIONS

Plain films
AP, lateral and open mouth view
Weakness : Optional: Oblique and Swimmers
upper > lower
CT
Better for occult fractures
Variable sensory loss
MRI
Very good for spinal cord, soft tissue and ligamentous
Sacral sparing injuries

Flexion-Extension Plain Films

to determine stability

ADEQUACY SWIMMERS VIEW

Must visualize entire C-spine

A film that does not show the
upper border of T1 is
inadequate
Caudal traction on the arms
may help
If can not, get swimmers
view or CT

ALIGNMENT LATERAL CERVICAL SPINE X-RAY

The anterior vertebral line,

posterior vertebral line, and
spinolaminar line should
have a smooth curve with no
steps or discontinuities
Malalignment of the
posterior vertebral bodies is
more significant than that
anteriorly, which may be due
to rotation
A step-off of >3.5mm is
significant anywhere
Anterior subluxation of one
vertebra on another
indicates facet dislocation
< 50% of the width of a
vertebral body unilateral
facet dislocation
> 50% bilateral facet
dislocation

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BONES DISC

Disc Spaces
Should be
uniform
Assess spaces
between the
spinous
processes

OPEN MOUTH VIEW CT SCAN

Thin cut CT scan

Adequacy: all of should be used to
the dens and evaluate abnormal,
lateral borders of suspicious or poorly
visualized areas on
C1 & C2 plain film
Alignment: lateral
masses of C1 and The combination of
C2 plain film and directed
Bone: Inspect dens
CT scan provides a
false negative rate of
for lucent fracture less than 0.1%
lines

MRI MANAGEMENT OF SCI

Ideally all patients Primary Goal

with abnormal Prevent secondary injury
neurological
examination should Immobilization of the spine begins in the
be evaluated with
initial assessment
MRI scan
Treat the spine as a long bone
Secure joint above and below
Caution with partial spine splinting

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MANAGEMENT OF SCI MANAGEMENT OF SCI

Spinal motion restriction: immobilization devices Look for other injuries: Life over Limb
ABCs Transport to appropriate SCI center once
Increase FiO2 stabilized
Assist ventilations as needed with c-spine control Consider high dose methylprednisolone
Indications for intubation :
Controversial as recent evidence questions benefit
Acute respiratory failure
Must be started < 8 hours of injury
GCS <9
Increased RR with hypoxia Do not use for penetrating trauma

PCO2 > 50 30 mg/kg bolus over 15 minute

VC < 10 mL/kg After bolus: infusion 5.4mg/kg IV for 23 hours
IV Access & fluids titrated to BP ~ 90-100 mmHg

PRINCIPLE OF TREATMENT JEFFERSON FRACTURE

Spinal alignment Burst fracture of C1 ring

deformity/subluxation/dislocation reduction
Unstable fracture

Spinal column stability Increased lateral ADI on

lateral film if ruptured
unstable stabilization transverse ligament and
displacement of C1 lateral
masses on open mouth view
Neurological status
neurological deficit decompression Need CT scan

BURST FRACTURE CLAY SHOVELERS FRACTURE

Fracture of C3-C7 from axial Flexion fracture of

loading
spinous process
Spinal cord injury is
common from posterior
displacement of fragments C7>C6>T1
into the spinal canal

Unstable Stable fracture

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FLEXION TEARDROP FRACTURE BILATERAL FACET DISLOCATION

Flexion injury causing a Flexion injury

fracture of the
Subluxation of
anteroinferior portion of
the vertebral body dislocated vertebra of
greater than the AP
diameter of the
Unstable because vertebral body below it
usually associated with High incidence of
posterior ligamentous spinal cord injury
injury
Extremely unstable

HANGMANS FRACTURE ODONTOID FRACTURES

Extension injury Complex mechanism of injury
Generally unstable
Bilateral fractures of
Type 1 fracture through the tip
C2 pedicles
(white arrow) Rare
Type 2 fracture through the base
Anterior dislocation of Most common
C2 vertebral body (red Type 3 fracture through the base and body
arrow) of axis
Best prognosis
Unstable

Odontoid Fracture Type II Odontoid Fracture Type III

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Anatomic
Classification

CLASSIFICATION OF 2 or 3
THORACOLUMBAR SPINE Columns Denis 83
FRACTURE
McAfee 83
Ferguson &
Allen84

Holdsworth62
Kelley &
Whitesides 68

ANATOMIC CLASSIFICATION ANATOMIC CLASSIFICATION

2 COLUMN THEORY 3 COLUMN THEORY
HOLDSWORTH 62 DENIS 83
Posterior Anterior

Six types- Nicols +2 Posterior Middle Anterior

Reviewed 1,000 patients 2 1 Based on radiographic review of 412

1
Anterior- vertebral body, ALL, PLL cases
Supports compressive loads 51 types, 20 subtypes 3 2 1
Posterior- facets, arch, Anterior- ALL , anterior 2/3 body
2 2
Inter-spinous ligamentous complex Middle - post 1/3 body, PLL
3
Resists tensile stresses Posterior- all structures posterior to PLL
Stressed importance of posterior Same as Holdsworth
elements Posterior injury-not sufficient to cause instability
If destabilized, must consider surgery

COMPRESSION FRACTURE BURST FRACTURE

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FRACTURE DISLOCATION FLEXION DISTRACTION

IMAGING
NON-OPERATIVE MANAGEMENT

SURGICAL INTERVENTION

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COMPLICATIONS OF SPINE FRACTURE

Neurological injury
Instability ( pain & deformity)
Complication of surgery

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