28.d.

Fracture of spine: first aid, classification and therapy

First Aid: Fracture of the Spine spinal cord may be crushed, cut, or otherwise damaged so severely that death or paralysis will result.However, if the fracture occurs in such a way that the spinal cord is not seriously damaged, there is a very good chance of complete recoveryPROVIDED the victim is properly cared for. Any twisting or bending of the neck or back, whether due to the original injury or carelessness from handling later, is likely to cause irreparable damage to the spinal cord. The primary symptoms of a fractured spine are pain, shock, and paralysis. o PAIN is likely to be acute at the point of fracture. It may radiate to other parts of the body. SHOCK is usually severe, but (as in all injuries) the symptoms maybe delayed for some time. o PARALYSIS occurs if the spinal cord is seriously damaged. If the vic-tim cannot move the legs, feet, or toes, the fracture is probably in the back; if the fingers will not move, the neck is probably broken. Remember that a spinal fracture does not always injure the spinal cord, so the victim is not always paralyzed.Any person who has an acute pain in the back or the neck following an injury should be treated as though there is a fractured spine, even if there are no other symptoms. First aid treatment for all spinal fractures,whether of the neck or of the back, has two primary purposes: o (1) to minimize shock and o (2) toprevent further injury to the spinal cord. Keep the victim comfortably warm. Do not attempt to keep the victim in the position ordinarily used for the treatment of shock, because it might cause further damage to the spinal cord. Just keep the victim lying flat and do NOT attempt to lower the head. To avoid further damage to the spinal cord,DO NOT MOVE THE VICTIM UNLESS IT IS ABSOLUTELY ESSENTIAL. If the victims life is threatened in the present location or transportation is necessary to receive medical attention,then of course you must move the victim.However, if movement is necessary, be sure that you do it in a way that will cause the least possible damage. DO NOT BEND OR TWIST THEVICTIMS BODY, DO NOT MOVE THE HEADFORWARD, BACKWARD, OR SIDEWAYS,AND DO NOT UNDER ANY CIRCUM-STANCES ALLOW THE VICTIM TO SIT UP. If it is necessary to transport a person who has suffered a fracture of the spine, follow these general rules:1.2.3.If the spine is broken at the NECK, the vic-tim must be transported lying on the back,FACE UP. Place pillows or sandbagsbeside the head so that it cannot turn toeither side. Do NOT put pillows or pad-ding under the neck or head.If you suspect that the spine is fracturedbut do not know the location of the break,treat the victim as though the neck isbrokeni.e., keep the victim supine. Ifboth the neck and the back are broken,keep the victim supine.No matter where the spine is broken, USEA FIRM SUPPORT IN TRANSPORT-ING THE VICTIM. Use a rigid stretcher,or a door, shutter, wide board, etc. Padthe support carefully and put blankets bothunder and over the victim. Use cravatbandages or strips of cloth to secure the vic-tim firmly to the support. o

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES General points In cases of neurological injury, initial intervention is aimed at reducing the secondary injury, preventing further deterioration and allowing return of neurological function in some cases. Most spinal trauma centres no longer use steroids in cases of spinal cord injury as there is no evidence that they work.

Basic management principles Spinal realignment In cases of cervical spine subluxation or dislocation, skull tongs are used to apply traction. The alternative is open reduction and operative realignment using internal fixation . A halo brace can be used to perform a closed realignment of cervical fractures . Stabilisation If a spinal fracture or dislocation is unstable (moves abnormally when stressed) there is a risk of new or further neurological injury as well as painful post-traumatic deformity. Many spinal injuries can be managed non-operatively with external support but, when possible, internal fixation should be used. The only absolute indication for surgery in spinal trauma is deteriorating neurological function. All other indications are relative. Early stabilisation has the advantage that it allows early mobilisation of the patient. Decompression of the neural elements Spinal realignment is important in this regard. Compression of the cord by bone and/or disc material requires surgical removal SPECIFIC SPINAL INJURIES Upper cervical spine (skull to C2) Craniocervical dislocation This injury is the consequence of high-energy trauma and is usually fatal. It may be anterior, posterior or vertical (Fig. 24.23). Powers ratiois used to assess skull translation. In survivors, careful occipitocervical fusion is required. A halo braceshould be applied before surgery to prevent intraoperative dislocation. Atlantoaxial instability The most common form is a rotatory subluxation in children. This is usually of spontaneous onset but can be traumatic. The 3 months followed by flexionextension stress radiography to check stability. Persistent C1/2 instability will need C1/2 or occiputC2 fusion. Odontoid fractures There are three types of odontoid fracture (Fig. 24.27). o Type I fractures are uncommon and are usually stable, requiring no immobilisation. o Type II fractures may fail to unite, particularly those with significant displacement on presentation and those in the elderly. o Type III fractures extend into the C2 vertebral body and usually readily unite. Neurological injury is rare. The majority of acute injuries are treated non-operatively in a halo jacket for 3 months. Internal fixation with an anterior compression screw is indicated in displaced fractures in younger patients with good bone quality (Fig. 24.28). Posterior C1/2 fusion is required in cases of non-union. Elderly patients often develop a fibrous pseudoarthrosis that is relatively stable and does not require surgery. Hangmans fracture This injury can be considered as a traumatic spondylolisthesis of C2/3 resulting from bilateral C2 pedicle fractures secondary to hyperextension (Fig. 24.29). The majority can be treated nonoperatively in a halo jacket or brace. Those with significant displacement or associated facet dislocation are treated operatively,usually with posterior stabilisation. Subaxial cervical spine (C3C7) The pattern of lower cervical spine injury depends on the mechanism of trauma. Many of the more severe injuries are associated with spinal cord injury. Wedge fracture This results from hyperflexion and is usually stable without neurological injury. It is treated in a brace or halo for 3 months.

Burst fracture This occurs secondary to axial loading of the cervical spine. Bony fragments may explode into the spinal canal and cause neurological injury (Fig. 24.30a). Surgical intervention may be required to remove the fractured vertebral body, decompress the spinal cord and then stabilise with internal fixation (Fig. 24.30b). Burst fractures without neurological deficit can be treated non-operatively in a halo jacket. Tear-drop fracture The mechanism of injury is hyperextension. Unstable fractures require operative treatment. Facet subluxation/dislocation The pattern of injury ranges from facet subluxation, through unifacetal dislocation to bifacetal dislocation (Fig. 24.31). Bifacetal dislocation is associated with spinal cord injury in the majority of cases. The mechanism of injury is a combination of axial loading and flexion leading to compression at the anterior aspect of the spine and distraction of the posterior elements. The majority are pure ligamentous injuries with associated disruption of the intervertebral intervertebral disc. Surgical stabilisation is required in most cases; awake, closed reduction with skeletal traction is recommended when possible. In cases of incomplete paralysis or normal neurology, a pre-traction MRI should be considered to identify disc herniations that may then press on the cord and damage it during reduction (Summary box 24.8). Thoracic and thoracolumbar fractures Fractures that are highly unstable with an associated risk of neurological deficit should be fixed surgically. The AO (Arbeitsgemeinschaft fr Osteosynthesefragen) classifies fractures into three main types, A, B and C, with injuries becoming progressively more unstable from A to C. There is also an increasing risk of associated neurological injury. o Type A fractures primarily involve the vertebral body. o Type B injuries have additional distraction/disruption of the posterior elements and o type C injuries are rotational. The majority of type B and type C injuries require surgical stabilisation. Burst fractures are included in type A. Thoracic spine (T1T10) Osteoporotic wedge compression fractures in the elderly are the most common injury in this group. These are stable so can be treated symptomatically. Fractures that remain symptomatic for more than 6 weeks can be treated with percutaneousbone cement augmentation, known as vertebroplasty.Specialised balloons can also be inserted and inflated in an attempt to restore vertebral height (kyphoplasty) and relieve pain (Fig. 24.32). The combination of thoracic spine disruption and a sterna fracture (Fig. 24.33) carries a significant risk of aortic rupture. Multiple posterior rib fractures and rib dislocations above and below a thoracic spinal injury signify a major rotational injury to the chest and are associated with vascular injury and significant pulmonary contusion (Fig. 24.34). Upper thoracic spinal column injuries can be difficult to diagnose with plain radiography. High-quality CT sagittal reformats are best. Posterior instrumentation is indicated in almost all unstable thoracic spinal injuries as braces do not provide adequate stability and the risk of neurological deterioration can be considerable. Thoracolumbar spinal fractures (T11S1) The thoracolumbar junction is prone to injury as it represents a transition zone from fixed to mobile segments. There is a wide spectrum of possible injuries, ranging from minor wedge fractures to spinal dislocation (Fig. 24.35). Burst fractures o These are comminuted fractures of the vertebral body. The distance between the pedicles is widened and bone is retropulsed into the spinal canal (Fig. 24.36). o Many of these fractures can be treated non-operatively.

Surgical intervention is indicated when there is neurological compromise or the fracture is unstable. Chance fractures o These are flexiondistraction injuries and are classically associated with the use of lap belts (Fig. 24.38). o They may be bony or soft tissue in nature and predominantly occur at the thoracolumbar junction. o Duodenal, pancreatic and/or aortic rupture can occur in these injuries and there must be a high index of suspicion