2. Anatomy of the Cord and Cauda
Spinal cord from foramen magnum to L1*
Conus at L1 for bowel and bladder (nervi
(eriganties S1-S5
L1 to S1 roots start innervation of lower *
extremities
Thoracic blood supply to the cord starts at*
(T10-T12 (artery of Adamkowitz
Lumbar blood supply is abundant*

4. Physiological Anatomy of the
Thoracic Spine
Facets lie in the frontal plane- allowing rotation 
Ribs resist rotation and add stiffness in lateral 
rotation
Kyphosis of the T spine loads the anterior 
column
Lower 2 vertebra have floating ribs and no 
costotransverse articulations
Canal size in thoracic spine relatively small 

5. Physiological Anatomy of the
Lumbar Spine
Large discs allow more ROM 
Facets prevent rotation 
Spinal canal wider 
Lordosis loads the facets 

6. Thoracolumbar Junction
Thoracic spine stiffer in flexion (ribs) than lumbar spine (stress
(riser
Lowest 2 thoracic vertebra have less extrinsic stability 
secondary to changes in facet orientation and floating ribs
(T11-12 have frontal facets but no conjoined ribs to stabilize,
(therefore less rotational resistance
In pure axial loading, thoracic spine deforms into kyphosis and
lumbar spine into lordosis leaving the transition vertebra
exposed to pure compression
Force distributed over 10 thoracic and 4 lumbar vertebra is 
withstood only by 2 vertebra at the thoracolumbar junction



7. Mechanisms of Injury
How much energy was imparted into the 
individual (fall from height vs fall from level
(skiing vs ejection from car
What was the loading force (impact onto 
buttocks vs impact onto flexed neck vs impact
(from object
What was the force trajectory (beam impact vs 
(restrained MVA vs collision with tree
What was the quality of the tissue of the 
recipient to resist force (young adult vs senior/
(preexisting pathology

8. CAUSES OF SCI

9. Patient History
Loss of consciousness 
(Loss of motor strength (temp or present 
(Sensory changes (temp or present 
(Incontinence (at scene vs current 
Localized pain to other areas 
(Dyspnea (pneumothorax 
Past medical history 

10. Patient Examination
ABCs first, then trauma examination 
Motor strength L1-S1(for suspected 
(thoracolumbar injury
Sensory C4-S3 
Reflexes (hyperreflexia asso. with preexisting 
(myelopathy
Rectal exam (sensory, tone and contraction) 
((missed conus injury
(Bulbocavernosis (if necessary 

11. STAGES
(Stage of spinal shock (Flaccid Stage 
sensation and motor power localized below the 
vertical height of the lesion are lost. This stage lasts
for 2 to 3 weeks in humans, and hours to days in
.other animals
(Stage of recovery (spastic stage 
after a period typically ranging from 2 to 3 weeks of 
injury, the nerves partially recover, and the return of
.segmental reflexes produce paraplegia-in-flexion
.

12. SYMPTOMS
The vertical location
of the injury
In general, injuries 
that are higher in
our spinal cord
produce more
. paralysis
The severity of the
( injury.(T S section
Spinal cord injuries 
are classified as
partial or complete,
depending on how
much of the cord
. width is damaged

13. Treatment of Neurologic
Injury
Methylprednisolone protocol (30 mg/kg 
loading and 5.4 mg/kg x 24 (or 48) hours
Only for central injuries- not peripheral nerve 
(injuries (conus is central injury

14. Mutiple Spinal Injuries
patterns 3 
Watch out for 
distracting injuries
of patients can 10% 
have other spinal
injuries
Severity of trauma- 
splenic/ liver and
vessel injury

15. Classification System
Holdsworth 2 column theory 
Denis 3 column theory 

16. Classification of Injuries
(Simple Compression (1-2 column injury 
(Stable burst (2-3 column injury 
(Unstable burst (3 column injury 
(Flexion distraction (2 nonconjoined columns 
(Chance (3 column failure all in tension 
(Fracture dislocation (3 column injury 
(Pure Dislocation (rare) (3 column injury 
(Pathological (any and all 
(Insufficiency (any and all 
(Multiple contiguous fractures (nly 1-2 columns 

17. Compression Fractures
Only anterior column injury 
Middle? and post. OK 
Ant. column less than 30% 
No more than 10 deg kyphosis 
No neuro injury 

18. Flexion distraction
Easy to miss- may 
look benign
Anterior column > 
50% crushed
Middle column 
mainly intact
Significant spinous 
process widening
Unstable 

19. Stable Burst
Both ant and middle 
column involvement
Minimal kyphosis 
No neuro 
involvement
No laminar fracture 

20. Unstable Burst
column 3 
involvement
Possible neuro 
involvement
Severe communition 
Significant pedicle 
widening
Look for laminar 
fracture (asso. with
( root entrapment

21. Chance Fractures
”Old “Seatbelt injuries 
Center of rotation is 
anterior to ALL
May be “bony” chance or 
purely ligamentous
Normally neuro intact 
Bony” stable,“ 
ligamentous unstable
even though all are 3
column injuries

22. Fracture Dislocations
Translation in lower 
lumbar spine may be
developmental (only L3(S1 spondylolysthesis
Always abnormal in 
(thoracic spine (ribs fix
Unstable 
Normally- neuro deficit 
Can be hidden at mid 
thoracic spine
column injury 3 

23. Pathological Fractures
Normally in patient with
history of CA

May be hard to distinguish
from insufficiency or
osteoporosis fracture
May be multiple levels


Fracture out of proportion
to force of trauma
Suspicion calls for MRIand ?
Bone scan



24. Insufficiency Osteoporosis
Fractures
Normally in elderly females 
Osteopenia/malacia 
Bones have “washed out” 
appearance
Minimal force vectors 
(Multiple levels (normally 
Kyphosis greater than 70 
degrees may need surgery
Vertebroplasty treatment? 

25. So how do you read the
?films
Look at alignment of vertebra 
On AP- measure pedicle distance and look for 
both SP splaying and laminar fractures
Measure kyphosis from intact endplates 
Measure anterior and middle column height 
Look for retropulsion 
High index of suspicion for other fractures 

26. Look at alignment
Look at how the 
anterior and posterior
aspects of the body
line up

27. Spinous Process Splaying
Indicative of either 
chance (stable) or
flexion distraction
(unstable) injury

28. Laminar Split
Associated with burst 
or flex-distraction
fractures
Look on exam for 
root injuries (they
become entrapped in
(lamina
Possible association 
with dural tear

29. Measure Kyphosis
Measure from closest 
intact endplates

30. Measure Ant. and Middle
Column Heights
Compare with 
vertebra above and
below

31. Measure pedicle distances
Compare to vertebra 
adjacent to injured
one

32. Anterior Column Fx
Treatment
Simple compressions can be 
placed in a Jewett or TLSO off
the shelf brace and discharged
from the ED or office as long as
pain is controlled, fracture is
stable with new standing x-rays
in brace and they don’t have an
ileus. Cannot treat fractures
above T6 without cervical
extension

33. Stable Bursts and Lateral
Compression Fractures
Admit- pain mgmt and 
neuro checks
Brace management -Off 
the shelf TLSO for simple
compressions greater
than 30% and lateral
compressions, Custom
TLSO for unusual body
habitis, severe bursts and
pts that need stability
testing. CASH for
insufficiency Fxs

34. Complications from Fracture
(/Pneumothorax (thoracic Fxs with asso rib Fxs 
(Ileus (30-60% 
(Splenic, liver and vessel injury (mechanism of injury
DVT/PE 
Decubitis 
UTI 
Pneumonia 
Renal failure (hydronephrosis from cauda equina 
(involvement


35. Stress Testing
Fracture that may be 
unstable
Bed rest until ambulance
arrives
X Rays supine/ 45deg/ 90
deg/ upright
Stop if neuro 
involvement, sig. Pain
increase or sig. Increased
kyphosis



36. degrees vs upright 45

37. Surgical Indications
Neurological Involvement 
Flexion distraction injury 
Greater than 50% canal compromise 
with >15 degrees kyphosis
degrees kyphosis 25< 
Failure of stress testing (severe pain, 
angulation above 25 degrees, neuro
(symptoms
Fracture dislocations 
Soft tissue “chance” fractures 

38. Time to healing
Most non-surgical fractures heal within 12 weeks 
Back support with braces(types)on whenever 
.patient upright
When healed- 4 weeks of PT for deconditioning 
Residuals of barometric sensitive discomfort and 
occasionally problems with lifting
may need to go on to surgery from % 10 
instability pain

39. NURSING BEDS
Clinitron Bed 
Tilt Bed 

40. ROTAREST BED

41. Thank You