SPINAL INJURIES

===============

These form a life changing problem for the majority of cases

because they lead to high rate of disability and affect young individuals.
The incidence of SI varies between 1-4%.
Spine fractures contribute for 10-20% of all skeletal fractures.

The incidence of the affected spine segments:

cervical fractures present 20-25%,
thoracic fractures 20-35%, and
lumbar fractures 35-40%

The spinal cord is affected in 25-40% of cases.

Focal neurological deficit is established in 70-90% of the lower cervical and
high thoracic fractures and dislocations.
Mortality varies from 6% to 34%.
Mortality in cervical injuries reaches 33%, in thoracic injuries 8-9% and in lumbar
injuries 6-7%.
Associated injuries lead to an increase in mortality rate.

Etiology:
--------
traffic accidents 40-50%;
falls 18-23%;
water jumps 8-10%;
sports accidents 4-7%;
penetrating SI (gun-shot and stab injuries) 7-14% of cases.

We can Classify it by many standards: According to:

-General Surgical Principles
-Damage to the Vertebral Column
-Mechanism of Injury
-Spinal Stability
-Localization of the SI
-Morphological Damage to the Spinal Cord

Expanded below:

-General Surgical Principles:

Closed -No skin laceration, divided into
-with vs
-without dmg to neural structures.
-Spinal dmg without fracture
Opened -There is skin laceration, can be divided into:
-Non-penetrating
-Penetrating
Transit, Blind, Tangential

-Damage to the Vertebral Column

Fractures
Fracture-dislocations
Distortions
Traumatic Disc Herniations

-Mechanism of Injury
Hyperflexion - axial vs lateral load
Hyperextension
Axial compression
Rotation mechanism
Lateral hyperflexion
Combined mechanism

-Spinal Stability
-Localization of the SI
Occipito-cervical injuries,
sub-axial injuries,
thoracic injuries,
thoraco-lumbar injuries,
lumbar injuries,
sacral injuries.

-Morphological Damage to the Spinal Cord

Concussion, contusion, compression

Pathology
---------
Injuries can be primary (focal and diffuse) and secondary.
Treatment efforts should aim at preventing complications as a result of
secondary injuries in order to minimise spinal cord damage.
There are two major pathogenic mechanisms underlying spinal cord damage:

-vascular mechanism - reduced regional blood flow,

local vasoconstriction, loss of autoregulation and endothelial damage
alter vascular permeability can result in thrombosis which will determine the
severity of secondary damage and prognosis;

-neuronal mechanism - direct damage to cell

membranes, then cytotoxic and vasogenic oedema
which eventually leads to posttraumatic cysts and loss of function.

Syndromes Resulting from Injury

------------------------------------
Spinal Shock: Decreased muscle tone and absence of somatic and
autonomous reflexes are common (flaccid paralysis,
hypotonia, bladder and bowel incontinence).
It results from a rapid onset of hyperstimulation which leads to overload
and blockage of neurotransmission. The spinal shock usually lasts
from several days to several weeks followed by the
development of the typical neurological signs of central
damage (spastic paralysis, hyperreflexia, pathological reflexes,
etc.)

Complete anatomical interruption:

1st stage – presents immediately after the acute trauma and
includes: anesthesia, total loss of motor function (plegia)
distal to the level of injury, hypotonia, loss of reflexes,
bowel and bladder disturbances;
2nd stage – it takes several weeks to develop the typical
clinical presentation anesthesia, signs of central paralysis53
including hyperreflexia with abnormal reflexes, spasticity,
urinary retention.

Anterior Cord Damage:

motor paralysis below the level of injury with sparing of proprioception and
vibratory sensation

Posterior Cord Damage:

loss of proprioception and vibratory sensation below the level of lesion with
sparing of motor functions (usually caused by a disease in non-trauma pts)

Lateral Cord Syndrome:

motor paralysis, loss of proprioception and vibratory sense on the same side
and loss of pain and temperature sensation on the side opposite to the lesion,
typically beginning 1 to 2 dermatomal levels below the injury.

Conus Medullaris Syndrome:

(S3 – S5 spinal cord segment) –
presents with urinary and bowel disturbance

Cauda Equina Syndrome:

presence of radicular pain and asymmetric dermatomal type of sensory and motor
deficit in the lower extremities

Central Cord Syndrome:

occurs in pts with cervical stenosis with hyperextension injury.
Cx'd by bigger motor impairment in the upper extremities than in the lower
extremities,
bladder dysfunction (usually urinary retention),
and variable degree of sensory loss below the level of the lesion.

Diagnosis of Spinal Injuries:

Xray
AP and lateral mandatory
Assess integrity of spine.
Paraspinal structures
Degenerative and Pathological diseases

Lumbar Puncture
Biochemical, Cytological, Bacterial CSF abnormalities.
Myelography
Check for compression of spinal cord, cauda equina, meningeal leakages
CT
Ligaments, bone fragments and compression of spinal canal, alien
bodies, disc
herniation
MRI
superior details about soft tissue changes.

Treatment:
Non Surgical:
-Manual Reposition - unilateral or bilateral dislocations
-Cervical traction - progressively increasing traction through brackets of
Crutchfield, Gardner-wells, Winke or Halo-traction.
-Postural reposition - applied to thoracic and lumbar spinal injuries,

Surgical
-Method of Choice for Severe SI:
i.e. compression of spinal cord, reduced vertebral height >50%,
instability of the segment)
Different operating approaches can be used based on the area that is
damanged, the type of injury
and preference of the surgeon.
 Generally Anterior, Lateral, Posterior or Combined approaches are used.

The main goal of the surgical treatment is to achieve reposition of the

affected segment, decompression of neural structures (spinal cord and
nerve roots) and stabilization of the affected segment.