INJURIES OF SPINE

Section 3 TRAUMA
Chapter 28 Injuries of Spine

PATHOPHYSIOLOGY OF SPINE INJURIES

A. Stable and unstable injuries
A stable injury is one in which the vertebral components will not be displaced by normal
physiological loads, whereas an unstable injury is one in which there is a significant risk of
displacement and damage to the neural tissues
3 Elements of spine ( Denis classification ) :

1. Posterior complex
2. Middle component
3. Anterior column
AO Classification :
1. Type A injuries – anterior column compression fractures which tend to be stable
2. Type B injuries – involve anterior and posterior columns with distraction; these are
unstable
3. Type C injuries – double-column injuries with rotation or sheer; these are unstable.

B. Pathophysiology
• PRIMARY CHANGES
Physical injury may be limited to the vertebral column, including its soft-tissue components,
and varies from ligamentous strains to vertebral fractures and fracture-dislocations
• SECONDARY CHANGES
During the hours and days following a spinal injury biochemical changes may lead to more
gradual cellular disruption and extension of the initial neurological damage
C. Mechanism of Injury
• TRACTION ( AVULSION ) INJURY
• DIRECT INJURY
• INDIRECT INJURY
D. Healing
Bony injuries tend to heal but the patient may be left with kyphosis or loss of height.
Ligamentous injuries seldom heal to a stable state and will potentially lead to progressive
kyphosis, chronic pain and further neurological sequelae.

EARLY MANAGEMENT
• Assessment and resuscitation according to a recognized protocol, such as the ATLS®
protocol
• Adequate oxygenation and perfusion helps minimize secondary spinal cord injury.
• Immobilization continues until spinal injury has been excluded by both clinical and
radiological assessment.
• Temporary immobilization with a semi-rigid collar and sandbags may be used when
transferring a spinal injury patient into a CT or MRI scanner.
• Log-rolling with spinal precautions is mandatory to avoid further
DIAGNOSIS
A. History
• The history is important and, with any high-energy injury such as high-speed traffic
accidents or falls from heights
• Unconscious and polytraumatized patients need to be considered as having an
unstable spinal injury until proven otherwise
B. Examination
• GENERAL EXAMINATION – ‘SHOCK’
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
• NEUROLOGICAL EXAMINATION

Nerve root Test

C5 Elbow flexion
C6 Wrist extension
C7 Wrist flexion, finger extension
Root
C8 Tendon reflex
Finger flexion
value
T1
C5 BicepsFinger abduction
L1,2
C6 Hip abduction
Brachioradialis
L3,4
C7 TricepsKnee extension
L5, S1
L3,4 Knee flexion
Quadriceps
L5
L5,S1 Great
Achilles toe extension
tendon
S1 Great toe flexion

C. Imaging
• X – ray
• MRI
• CT Scan

PRINCIPLES OF DEFINITIVE TREATMENT

The objectives of treatment are:
• to preserve neurological function
• to minimize a perceived threat of neurological compression
 • to stabilize the spine
• to rehabilitate the patient
Stability
‘Clinical instability’ is defined as a loss in the ability of the spine, under physiologic loads, to
maintain relationships between vertebrae in such a way that there is neither damage nor
subsequent irritation to the spinal cord or nerve roots.
Patients with no neurological injury
• STABLE INJURIES
• UNSTABlE INJURIES
Patients with a neurological injury
• STABLE SPINAL INJURIES
• UNSTABLE SPINAL INJURIIES
• MEDICAL TREATMENT OF CORD INJURIES

TREATMENT METHODS
Cervical Spine :
• Collars
• Tongs
• Halo ring
• Fixation

Thoracolumbar spine :
• Beds
• Brace
• Decompression and stabilization

CERVICAL SPINE INJURIES

A. Imaging
• AP and Lat view
• Open mouth view
 B. Diagnosis pitfalls in children
• An increased atlantodental interval (up to 5 mm) may be quite normal
• An increased retropharyngeal space can be caused by crying
• SCIWORA

I. UPPER CERVICAL SPINE

Occipital Condyle Fracture
A high-energy fracture and associated skull or cervical spine injuries must be sought.
The diagnosis is likely to be missed on plain X-ray
examination and CT is essential
Occipital dislocation
The diagnosis can sometimes be made on the lateral cervical radiograph: the tip of the
odontoid should be no more than 5 mm in vertical alignment and 1 mm in horizontal
alignment from the basion (anterior rim of the foramen magnum)

C1 ring fracture
An axial load may result in a burst fracture of the ring of the atlas (Jefferson’s fracture
C2 Traumatic Spondylolisthesis
This is not frequently seen today but rather a hyperextension mechanism from a force to the
forehead and the ‘Forsyth mechanism’ causing a resultant anterior translation at C2

C2 odontoid process fracture

They usually occur as flexion injuries in young adults after high-velocity accidents. They also
occur in elderly, osteoporotic people as a result of low-energy trauma in which the neck is
forced into hyperextension, such as a fall onto the face or forehead
Classification
• Type I - an avulsion fracture of the tip of the odontoid process due to traction by the
alar ligaments
• Type II – a fracture at the junction of the odontoid process and the body of the axis
• Type III – a fracture through the body of the axis.

TREATMENT
 Type I fractures
Isolated fractures of the odontoid tip are stable. They need no more than immobilization in a
rigid collar until discomfort subsides.
 Type II fractures
Management can be non-operative with a period of traction followed by collar or halo vest. In
the very elderly, a collar is appropriate due to the poor risk-to-benefit ratio of surgery
 Type III fractures
Undisplaced fractures are treated in a halo vest for 8–12 weeks. If displaced, attempts should
be made at reducing the fracture by halo traction

II. LOWER CERVICAL SPINE

Fractures of the cervical spine from C3 to C7 (subaxial cervical spine) tend to produce
characteristic fracture patterns, depending on the mechanism of injury
The SLIC scoring system (Table 28.3) incorporates three main characteristics:
• Morphology of the injury – This is based on the available imaging, and consists of
compression, distraction and translation/rotation of the vertebral bodies.
• Discoligamentous complex (DLC) – This considers the integrity of the intervertebral disc,
anterior and posterior ligamentous structures. They are defined as disrupted, intact and
indeterminate. The DLC is considered directly proportional to stability.
• Neurological status of the patient – This is linked with the severity of the injury.
The SLIC scale
Characteristic Points
Morphology
No abnormality 0
Compression 1
Burst +1 = 2
Distraction 3
Disrupted 4
Discoligamentous complex (DLC)
Intact 0
Indeterminate 1
Disrupted 2
Neurological status
Intact 0
Root injury 1
Complete cord injury 2
Incomplete cord injury 3
Continuous cord compression in setting of
+1
neurological deficit

Flexion injuries
These include distractive flexion and compressive flexion injuries. Depending on the
instantaneous axis of rotation during the injury, there is a spectrum from
posterior ligament disruption ranging to anterior column compression.
Wedge compression fracture (compressive flexion mechanism)
This results in a wedge compression fracture of the vertebral body
Burst and ‘teardrop’ fractures (compressive flexion mechanism)
These severe injuries are due to axial compression of the cervical spine with flexion, usually
in diving or athletic accidents. If the vertebral body is crushed in neutral position of the neck,
the result is a ‘burst fracture’. With an increasing flexion moment, the anteroinferior
fragment of the vertebral body is sheared off, producing the eponymous ‘teardrop’ on the
lateral X-ray. In both types of fracture there is a risk of posterior displacement of the
vertebral body fragment and spinalcord injury.
TREATMENT
 Conservative treatment of these injuries is a poor option
 Surgical management is the treatment of choice. The primary goal is stabilization and
neurological decompression as a secondary goal since the cord injury is often already
 established. The patient is initially stabilized in traction, optimized medically with
respect to spinal cord and concomitant injuries and appropriately imaged

An innocuouslooking fracture at C6 with

a large pre-vertebral swelling heralds the
‘teardrop’ fracture; note the mild
retrolisthesis.

Surgical stabilization with corpectomy

and anterior cervical plating.

Posterior ligament injury, dislocations and fracture-dislocations (distractive flexion

mechanism)
 Posterior ligament injury
Posterior spinous tenderness or gap should alert the clinician to this injury. X-ray may
reveal only an increased interspinous gap

 Bilateral facet joint dislocations (jumped facets)

These are severe flexion injuries with complete disruption of the posterior ligamentous
complex and spinal instability, often with cord damage. Occasionally facet fractures
occur.
 Unilateral facet dislocations (UFDs)
These are distractive flexion–rotation injuries with a single facet joint dislocation and
cord injury is less common.
Management of unifacet injuries and bilateral dislocations is the same. The dislocation
must be reduced as a matter of urgency due to ongoing cord compression.
TREATMENT
 Pre-reduction imaging
X-rays will diagnose the injury and are mandatory. CT is useful to exclude a facet
fracture not appreciable on plain X-rays which may prevent closed reduction. The MRI
scan will demonstrate disc, cord and ligament injuries as well as the facet dislocation

 Closed cervical reduction

Skull traction is used, starting with 5 kg and increased step-wise by similar amounts up to
about 30 kg; intravenous muscle relaxants and a bolster beneath the shoulders may help.
 Surgical open reduction
Practically this takes longer to accomplish since a CT or MRI is normally required,
theatre takes time to set up and preparation takes longer than closed reduction.
 Surgical stabilization
The options are anterior, posterior or combined approaches to reduce and stabilize the
dislocation. With anterior approaches, the disc is removed from the canal and the facets
indirectly reduced by manipulation of the vertebrae.
Hyperextension injury (distraction or compression combined with extension)
Hyperextension strains of soft-tissue structures are common and may be caused by
comparatively mild acceleration forces. Bone and joint disruptions, however, are rare.

Double injuries
With high-energy trauma the cervical spine may be injured at more than one level.
Discovery of the most obvious lesion is no reason to drop one’s guard

Avulsion injury of the spinous process

 Fracture of the C7 spinous process may occur with severe voluntary contraction of the
muscles at the back of the neck; it is known as the clay-shoveller’s
fracture.

Cervical disc herniation

Acute post-traumatic disc herniation may cause severe pain radiating to one or both upper
limbs, and neurological symptoms and signs ranging from mild paraesthesia to weakness,
loss of a reflex and blunted sensation. Rarely, a patient presents with full-blown paresis.
The diagnosis is confirmed by MRI.
Neurapraxia of the cervical cord
Accidents causing sudden, severe axial loading with the neck in hyperflexion or
hyperextension are occasionally followed by transient pain, paraesthesia and weakness in
the arms or legs, all in the absence of any X-ray or MRI abnormality. Symptoms may last
for as little as a few minutes or as long as 2–3 days. Treatment consists of reassurance
(after full neurological investigation) and graded exercises to improve strength in the neck
muscles
III. WHIPLASH INJURY (SPRAINED NECK/ CERVICAL ACCELERATION-
DECELERATION INJURY)
Soft-tissue sprains of the neck are so common after motor vehicle accidents that they now
constitute a veritable epidemic. There is usually a history of a low velocity rear end
collision in which the occupant’s body is forced against the car seat while his or her head
flips backwards and then recoils in flexion. This mechanism has generated the
imaginative term ‘whiplash injury’.
Clinical features
Often the victim is unaware of any abnormality immediately after the collision. Pain and
stiffness of the neck usually appear within the next 12–48 hours, or occasionally only
several days later. X-ray examination may show loss of cervical lordosis, a sign of muscle
spasm; or this finding may be a normal variant for the age group
Differential diagnosis
The diagnosis of sprained neck is reached largely by a process of exclusion, i.e. the
inability to demonstrate any other credible explanation for the patient’s symptoms. Seat-
belt injuries often accompany neck sprains.
Grade Clinical pattern
0 No neck symptoms or signs
 Neck pain, stiffness and tenderness
1
No physical signs
2 Neck symptoms and musculoskeletal signs
3 Neck symptoms and neurological signs
4 Neck symptoms and fracture or dislocation

Treatment
Collars are more likely to hinder than help recovery. Simple pain-relieving measures,
including analgesic medication, may be needed during the first few weeks
Progress and outcome
The natural history of whiplash injury is reflected in the statistics appearing in the medical
literature on this subject. Negative prognostic indicators have been suggested to be increasing
age, severity of symptoms at the outset, prolonged duration of symptoms and the presence of
pre-existing intervertebral disc degeneration.
Whiplash-associated disorder (chronic whiplash syndrome)
Those patients who, in the absence of any objective clinical or imaging signs, continue almost
indefinitely to complain of pain, restriction of movement, loss of function, depression and
inability to work constitute a sizeable problem in terms of medical resources, compensation
claims, legal costs and – not least – personal suffering.

THORACOLUMBAL INJURIES
Most injuries of the thoracolumbar spine occur in the transitional area – T11 to L2 – between
the somewhat rigid upper and middle thoracic column and the flexible lumbar spine.
Pathogenesis
Pathogenic mechanisms fall into three main groups:
1. low-energy insufficiency fractures – arising from comparatively mild compressive stress in
osteoporotic bone
2. minor fractures of the vertebral processes – due to compressive, tensile or torsional strains
3. high-energy fractures or fracture-dislocations – due to major injuries sustained in motor
vehicle collisions, falls or diving from heights, sporting events,
horse-riding and collapsed buildings.
The common mechanisms of injury are compression, rotation/translation and distraction.
Examination
Patients complaining of back pain following an injury or showing signs of bruising and
tenderness over the spine.

Imaging
  X-RAYS
 HELICAL CT SCANNING
 MRI
Treatment
Treatment depends on:
(1) the type of anatomical disruption;
(2) whether the injury is stable or unstable;
(3) whether there is neurological involvement; and
(4) the presence or absence of concomitant injuries.
I. MINOR INJURIES
Fractures of the transverse processes
The transverse processes can be avulsed with sudden muscular activity. Isolated injuries need
no more than symptomatic treatment

Fractures of the pars interarticularis

A stress fracture of the pars interarticularis should be suspected if a gymnast, athlete or
weightlifter complains of the sudden onset of back pain during the course of strenuous
activity. The injury is often ascribed to a disc prolapse, whereas in fact it may be a stress
fracture of the pars interarticularis (traumatic spondylolysis)
TREATMENT : An acute fracture usually heals spontaneously, provided the patient is
prepared to forego sporting activities for several months

II. MAJOR INJURIES

Flexion–compression injury
This is by far the most common vertebral fracture and is due to severe spinal flexion,
although in osteoporotic individuals fracture may occur with minimal trauma.
TREATMENT: Patients with minimal wedging and a stable fracture pattern are kept in bed
for a week or two until pain subsides and they are then mobilized; no support is needed.
Those with moderate wedging (loss of 20–40% of anterior vertebral height) with no
instability (disruption of the PLC) can be allowed up after a week, wearing a thoracolumbar
brace or a body cast applied with the back in extension.

Axial compression or burst injury

Severe axial compression may ‘explode’ the vertebral body, causing failure of the anterior
vertebral column. The posterior part of the vertebral body is shattered and fragments of bone
and disc may be displaced into the spinal canal. The injury is often
stable, depending on the posterior ligamentous complex integrity. Anteroposterior X-rays
may show spreading of the vertebral body with an increase
of the interpedicular distance

TREATMENT

If there is minimal anterior wedging and the fracture is stable (PLC intact) with no
neurological damage, the patient is kept in bed until the acute symptoms settle (usually under
a week) and is then 28 mobilized in a thoracolumbar brace or body cast which is worn for
about 12 weeks.
Fractures with more than 50% canal compromise on CT and/or neurological deficits also
tend to be unstable, requiring fixation. Canal decompression can be indirect or direct.
Indirect decompression is achieved with pedicle screw fixation and posterior distraction,
utilizing the intact posterior longitudinal ligament (PLL) to reduce retropulsed fragments
from the canal.
Chance injury (jack-knife injury or seat-belt fracture)
Combined flexion and posterior distraction may cause the mid-lumbar spine to jack-knife
around an axis that is placed anterior to the vertebral column. This is seen most typically in
lap seat-belt injuries, where the body is thrown forward against
the restraining strap.
TREATMENT
The Chance fracture (being an ‘all-bone’ injury) heals rapidly and can be managed
conservatively with bed rest and bracing. Posterior fixation is cost-effective
and allows early mobilization
Fracture-dislocation
Segmental displacement may occur with various combinations of flexion, compression,
rotation and shear. All three columns are disrupted and the spine is grossly unstable. These
are the most dangerous injuries and are often associated with neurological damage to the
lowermost part of the cord or the cauda equina.
TREATMENT
There is little place for conservative management of these highly unstable fractures. Most
patients have neurological deficits, and surgical stabilization allows easier nursing care and
results in lower patient morbidity, decreased hospitalization costs and earlier rehabilitation.

NEURAL INJURIES
In spinal injuries the displaced structures may damage the cord or the nerve roots, or both;
cervical lesions may cause quadriplegia, thoracolumbar lesions paraplegia. The damage may
be partial or complete
Neurapraxia
Motor paralysis (flaccid), burning paraesthesia, sensory loss and visceral paralysis below the
level of the cord lesion may be complete, but within minutes or a few hours recovery begins
and soon becomes full.
Cord transection
Motor paralysis, sensory loss and visceral paralysis occur below the level of the cord lesion;
as with cord concussion, the motor paralysis is at first flaccid. This is a temporary condition
known as cord shock, but the injury is anatomical and irreparable.
Root transection
Motor paralysis, sensory loss and visceral paralysis occur in the distribution of the damaged
roots. Root transection, however, differs from cord transection in two ways: recovery may
occur and residual motor paralysis remains permanently flaccid.
ANATOMICAL LEVELS
 Cervical spine
 Between T1 and T10 vertebrae
 Below T10 vertebra
 INCOMPLETE CORD INJURY SYNDROMES
Persistence of any sensation distal to the injury (perianal pinprick is most important)
suggests an incomplete lesion.
 The commonest is the central cord syndrome where the initial flaccid weakness is
followed by lower motorneuron paralysis of the upper limbs with upper motorneuron
(spastic) paralysis of the lower limbs, and intact perianal sensation (sacral sparing)
 Less common anterior cord syndrome there is complete paralysis and anaesthesia but
deep pressure and position sense are retained in the lower limbs (dorsal column
sparing)
 The Brown-Séquard syndrome (due to cord hemisection) is usually associated with
penetrating thoracic injuries. There is loss of motor power on the side of the injury
and loss of pain and temperature sensation on the opposite side
MANAGEMENT OF TRAUMATIC PARAPLEGIA AND QUADRIPLEGIA
 Skin
Pressure sores can develop in a few hours; prevention is with regular 2-hourly log-
rolling, pressure care and pressure-reducing mattresses.
 Bladder and bowel
Bladder training is begun as early as possible
 Muscles and joints
The paralysed muscles, if not treated, may develop severe flexion contractures. These
are usually preventable by moving the joints passively through their full range twice
daily. Later, splints may be necessary. If flexion contractures have been allowed to
develop, tenotomies may be necessary
 Tendon transfers
Some function can be regained in the upper limb by the use of tendon transfers. The
aim with patients who have a low cervical cord injury is to use the limited number of
functioning muscles in the arm to provide a primitive pinch mechanism (normally
powered by C8 or T1 which, being below the level of injury, are lost)