Most important aspect in daily accident occurrence for insistence of MOTOR VEHICLE ROAD TRAFFIC ACCIDENT.

1. FADHIL M. KALOKOLA
DAVID B. MBANYE
PHILEMON RAHAEL
(MD5)

2. Outlines
Introduction
Aetiology & Epidemiology
Mechanism of injury
classification
Neurological evaluation
Work up
Management
Complications

3. 31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
Spinal cord:
Extends from medulla oblongata – L1
Lower part tapered to form conus
medullaris
Enclosed within 33 vertebrae
Anatomy :

5. On the surface :
Deep anterior median fissure
Shallower posterior median sulcus
Spinal cord segment :
Section of the cord from which a pair of spinal
nerves are given off

6.  Dorsal root – sensory fibres
Ventral root – motor fibres
Dorsal and ventral roots join at intervertebral
foramen to form the spinal nerve

8. Physiology and function
Grey matter – sensory and motor nerve cells
White matter – spinal tracts
- Ascending, descending and intersegmental tracts

9. Tracts :

10. Posterior column and lateral corticospinal tract
crosses over at medulla oblongata
Spinothalamic tract crosses in the spinal cord and
ascends on the opposite side
NB
Understanding this helps to reveal the clinical
features of injury patterns and the neurological
deficit

11. Dermatomes
Area of skin innervated by sensory axons within a
particular segmental nerve root
Knowledge is essential in determining level of injury
Useful in assessing improvement or deterioration

12. Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier

13. Myotomes :
Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs:
C5 - Deltoid
C6 - Wrist extensors
C7 - Elbow extensors
C8 - Long finger flexors
T 1 - Small hand muscles
Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Kneeflexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion

14. Definition
Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic function.
This change is either temporary or permanent.

15. Terminologies
Plegia = complete lesion
Paresis = some muscle strength is preserved
Tetraplegia (or quadriplegia)
Injury of the cervical spinal cord
Patient can usually still move his arms using the segments above the
injury (e.g., in a C7 injury, the patient can still flex his forearms, using
the C5 segment)
Paraplegia – paralysis of both LL
Injury of the thoracic or lumbo-sacral cord, or cauda equina
Hemiplegia
Paralysis of one half of the body
Usually in brain injuries (e.g., stroke)
Monoplegia is a paralysis of one limb only.
Diplegia is a paralysis of two corresponding limbs (i.e., arms or
legs).

16. Causes of SCI

17. CAUSES
MVA
Falls
Violence
Sports injuries
Gunshot Injuries
Diving accidents
 Blunt Assault
 Stab Wounds
 Sport Injuries
55% cases occur in 16 – 30yrs of age
> 80% are male!

18. Other causes:
Vascular disorders
Tumours
Infectious conditions
Spondylosis
Iatrogenic
Vertebral fractures secondary to osteoporosis
Development disorders

19. Mechanisms:
i) Direct trauma
ii) Compression by bone fragments / haematoma /
disc material
iii) Ischemia from damage / impingement on the
spinal arteries

20. Patterns of injury
Fracture
Dislocation
Fracture dislocation
SCIWORA

21. SCI - Classification

22. ASIA – American Spinal Injury Association
Based on neurological responses, touch & pinprick
sensation (dermatome), +muscle strength.
A – Complete: no sensory or motor function preserved in
sacral segments S4– S5
B – Incomplete: sensory, but no motor function in sacral
segments
C – Incomplete: motor function preserved below level and
power graded < 3
D – Incomplete: motor function preserved below level and
power graded 3 or more
E – Normal: sensory and motor function normal

23. Can be
1) Complete
2) Incomplete
Complete:
i) Loss of voluntary movement of parts innervated by
segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock

24. Incomplete:
i) Some function is present below site of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although they
are rarely pure and variations occur

25. Incomplete injury syndromes
i) Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome

26. i) Central Cord Syndrome :
 Typically in older patients
 Hyperextension injury
 Compression of the cord anteriorly by osteophytes
and posteriorly by ligamentum flavum

27. Also associated with fracture dislocation and
compression fractures
More centrally situated cervical tracts tend to be
more involved hence
flaccid weakness of arms > legs
Perianal sensation & some lower extremity movement
and sensation may be preserved

30. ii) Anterior cord Syndrome:
Due to flexion / rotation
Anterior dislocation / compression fracture of a
vertebral body encroaching the ventral canal
Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia of
blood supply (anterior spinal arteries)

32. Clinically:
Loss of power
Decrease in pain and sensation below lesion
Dorsal columns remain intact

33. ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures of the
posterior elements of the vertebrae
Clinically:
 Proprioception affected – ataxia and faltering gait
 Usually good power and sensation

35. Brown-Sequard syndrome

36. v) Cauda Equina Syndrome:
 Due to bony compression or disc protrusions
in lumbar or sacral region
Clinically
Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness

37. Spinal Shock
Transient reflex depression of cord function below level of
injury
Initially hypertension due to release of catecholamines
Followed by hypotension
Flaccid paralysis
Bowel and bladder involved
Sometimes priaprism develops
Symptoms last several hours to days

38. Asessment
Spinal shock
Bulbocavernosus reflex
Complete VS incomplete cord injury
 spinal shock
Sacral sparing
 Voluntary anal sphincter control
 Toe flexor
 Perianal sensation
 Anal wink reflex

39. Neurogenic shock:
Triad of - i) hypotension
ii) bradycardia
iii) hypothermia
More commonly in injuries above T6
Secondaryto disruption of sympathetic outflow from
T1 – L2

40. Loss of vasomotor tone – pooling of blood
Loss of cardiac sympathetic tone – bradycardia
Blood pressure will not be restored by fluid
infusion alone
Massive fluid administration may lead to overload
and pulmonary edema
Vasopressors may be indicated

41. Autonomic dysreflexia (AD)
 A syndrome of massive imbalanced reflex sympathetic
discharge
 Occurring in patients with spinal cord injury (SCI)
 48-90% in patients with SCI above T6
 Above the splanchnic sympathetic outflow (T5-T6).
 Primarily a male phenomenon; M:F=4:1
 About 66% in females in labour

42. Pathophysiology
Occurs after the phase of spinal shock in which reflexes return.
Below the injury, intact peripheral sensory nerves transmit
impulses
That ascend in the spinothalamic and posterior columns
Stimulate sympathetic neurons located in the intermediolateral
gray matter of the spinal cord.

43. Inhibitory outflow above the SCI from vasomotor centres is
increased,
Unable to pass below the block of the SCI.
Release of various neurotransmitters (dopamine-b-hydroxylase,
norepinephrine, dopamine),
Causing piloerection, skin pallor, and severe vasoconstriction in
arterial vasculature.
Sudden elevation in blood pressure + vasodilatation above the
level of injury.
Headache caused by vasodilation of pain sensitive intracranial
vessels.

44. Increase in parasympathetic vagal tone by Vassomotor centers
compensatory bradycardia.
Parasympathetic nerves prevail above the level of injury 
sweating and vasodilatation with skin flushing.

45. Clinically
Headaches, and a sense of anxiety
sudden rise in both systolic and diastolic blood pressures, usually
with bradycardia
profuse sweating above the level of lesion,
flushing of the skin
nasal congestion is common.

46. Neurological evaluation
Motor: how to test each segment?

47. Sensory: how to determine the
level?

48. Spinal assessment
Palpate entire spine
Deformity
Grating / crepitus
Tenderness
Gapping interspinous spaces
Bogginess
Lacerations
DRE, perineal sensation + tone

49. Imaging modalities
CT scan
MRI
X-ray
- standard trauma series is composed of 5 x-ray views:
cross-table lateral,
swimmer's,
oblique,
odontoid,
Anteroposterior
Radiographic level = the level of fracture on plain XRays / CT scan /
MRI
NB: spine level does not correspond to spinal cord level below
the cervical region

50. Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
 Adequacy, Alignment
 Bone abnormality, Base of skull
 Cartilage
 Disc space
 Soft tissue

51. Alignment
• 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

52. Bones

53. Disc
Disc Spaces
Should be uniform
Assess spaces
between the spinous
processes

54. AP C-spine Films
Spinous processes should
line up
Disc space should be
uniform
Vertebral body height
should be uniform. Check
for oblique fractures.

55. Swimmer’s view

56. Open mouth view
Adequacy: all of the: all of the
dens and lateraldens and lateral
borders of C1 & C2borders of C1 & C2
Alignment: lateral: lateral
masses of C1 and C2masses of C1 and C2
Bone: Inspect dens
for lucent fracture
lines

57. Management

58. Management….
Advance Trauma Life Support (ATLS) guidelines
Primary survey; ABCDE
-Adequate airway and ventilation are the most
important factors
Supplemental oxygenation
Early intubation is critical to limit secondary injury
from hypoxia
Secondary surveys (e.g. Hx)
Initial Management

59. Immobilization
Entire spine until when the x-ray are available
Supine, no rotation no bending
It protect further damage
-Beware of decubitus ulcers

60. Methods of immobilization
Rigid collar
(Philadelphia hard collar)>>>
Sandbags and straps
Spine board
Braces
Log-roll to turn

62. Logrolling
At least 4 people
 1 Maintain inline manual immobilization
 1 For the torso (trunk)
 1 For the pelvis and legs
 1 To direct the move
Move the pt towards the attendants as a unit
Maintain neutral position of the spine
Children have proportionally large heads

64. IV fluids
Persistent hypotension after 2 liters  neurogenic shock
Use of vasopressors Dopamine / Adrenalin
Invasive monitoring; CVP and urethral catheters
Steroids
Methylprednisolone - 30mg/kg in the first 15min
Then 5.4mg/kg/hr for 24-48hrs
Exclusion criteria
 Cauda equina syndrome
 Pregnancy
 Age <13 years
 Patient on maintenance steroids

65. Mnx … cont
NGT
Prevents aspiration
Decompresses the abdomen (paralytic ileus is common in the first
days)
Foley catheter
Urinary retention is common and
For monitoring
- Spinal assessment

66. Care of paraplegics
Skin care
Bowel and bladder
Psychological support
Wheelchair
rehabilitation

67. Surgical Mnx
Indications for surgery
Instability
maintaining alignment to allow development of solid bone
fusion;
preventing progression of deformity;
alleviating pain
progressive neurological deficit
???? For early rehabilitation????

69. complications
Hypotension
Neurogenic pain
Spinal shock
hypothermia
paraplegia
Sexually dysfunction
Bladder + bowel
dysfunction
-Incontinence
-paralytic ileus
-urinary problems (UTI)
Weight loss or gain
Depression
Autonomic dysreflexia
Pressure sores (bed sores)
Pneumonia and asthma
CVS diseases
Spasm
syringomyelia
Deep vein thrombosis
-pulmonary embolism

70. References:
1. ATLS, et al. Student Course Manual. 7th
Edition
2004;7:177-204
2. Keith L Moore et al. Clinically Orientated Anatomy. 3rd
Edition1992;4:359
3. Snell.Clinical.Neuroanatomy.7th.2009
4. Essential of Orthopedics