Dr.MD.Monsur Rahman,PT MPT-Musculoskeletal Disorders Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)

1. Spinal injury
. .Dr MD MONSUR RAHMAN
( )PT
-MPT Musculoskeletal Disorders
, , ( ).Final Year MMIPR MM DU

2. Outline
• Incidence
• Types
• Clinical signs
• Radiological signs
• Spinal shock
• Management

3. Incidence
• 10 - 15 per million
• 18 - 35 years
• Male - 3:1
• RTA 51% - cars
• Domestic 16%
• Industrial 11%
• Sports 16% - diving incidents
• Self harm 5%

4. Types
• Cervical 40%
• Thoracic 10%
• Lumbar 3%
• Dorso lumbar 35%
• Any 14%

5. Cervical spine anatomy

8. • Anterior column - Anterior longitudinal ligament+
Anterior annular ligament and anterior half of VB.
• Middle column – Posterior long. Lig. + Posterior
annular ligament +Posterior half of VB.
• Posterior Column – Lig flavum + superior &
Interspinous lig + intertransverse capsular lig + neural
arch + pedicle & spinous process.

10. Significance
• Unstable if middle column + either Anterior or
Posterior column is damaged
• Rupture of interspinous ligament is :
- associated with avulsion of spinous process
- Unstable spine
- Further flexion increases neurological injury

11. Level of Spinal injury
• Neurological level is at the most lowest segment with
normal motor & sensory function
• Difficult to determine :
- as most muscle efferents receive fibres from more
than one level
- Closed cord lesions may extend over several cms.
- Dermatomes have imprecise boundaries.

12. Cord level
• C2 – C7 = add +1 for cord level
• T1 – T6 = add +2
• T7 – T9 = add +3
• T10 = L1, L2 level
• T11 = L3, L4 level
• L1 = sacro coccygeal segments

13. Degrees of injury
• Complete - flaccid paralysis + total loss of sensory &
motor functions
• Incomplete - mixed loss
- Anterior sc syndrome
- Posterior sc syndrome
- Central cord syndrome
- Brown sequard’s syndrome
- Cauda equina syndrome

14. Anterior spinal cord syndrome
• Flexion rotational force to spine
• Due to compression fracture of vertebral body or
anterior dislocation
• Anterior spinal artery compression
• Loss of power, reduced pain and temperature below
the lesion.

15. Posterior cord syndrome
• Hyperextension injuries
• Posterior vertebral body fracture
• Loss of proprioception and vibration sense
• Severe ataxia

16. Central cord syndrome
• Older age with cervical spondylosis
• Hyperextension with minor trauma
• Cord is compressed by osteophytes from vertebral
body against thick ligamentum flavum.
• Damages the central cervical tract
• UMN lesion to legs (spastic)
• LMN to arms (flaccid paralysis)

17. Brown sequards syndrome
• Hemisection of the cord
• Stab injury and lateral mass fractures
• Uninjured side has good power but absent pinprick
and temperature.
• Spinothalamic tracts cross to opposite side of the cord
three segments below.

18. Types of bony injury
• Flexion
• Extension
• Flexion with rotation
• Compression

19. Pathophysiology
• Primary Neurological damage
Direct trauma, haematoma & SCIWORA < 8yrs old
In 4hrs - Infarction of white matter occurs
In 8hrs - Infarction of grey matter and irreversible paralysis
• Secondary damage
Hypoxia
Hypoperfusion
Neurogenic shock
Spinal shock

20. Hypoxia
• Lesions above C5 – damage to diaphragm leads to 20%
reduction in vital capacity Rx Phrenic n. pacing
• Lesions at D4-6 – reduces vital capacity if < 500ml patient is
ventilated
• Intercostal nerve paralysis
• Atelectasis – poor cough
• V/Q mismatch
• Reduced compliance of lung – muscle fatigue.

21. Neurogenic shock
• Lesions above D6
• Minutes – hours (fall of catecholamines may take 24 hrs)
• Disruption of sympathetic outflow from D1 - L2
• Unapposed vagal tone
• Peripheral vasodilatation
• Hypotension, Bradycardia & Hypothermia
• BUT consider haemmorhagic shock if – injury below D6,
other major injuries, hypotension with spinal fracture alone
without neurological injury.

22. Spinal shock
• Transient physiological reflex depression of cord function –
‘concussion of spinal cord’
• Loss anal tone, reflexes, autonomic control within 24-72hr
• Flaccid paralysis bladder & bowel and sustained Priapism
• Lasts even days till reflex neural arcs below the level recovers.

23. Assessment & Managemnt
• Failure to suspect leads to failure to detect injuries
• ABCDE
• Look for markers of spinal injury
• Secondary survey
• Adequate Xray’s
• Emergency treatment
• Surgery
• Definitive care & rehab.

24. Clinical features
• Pain in the neck or back radiating due to nerve root
irritation
• Sensory disturbance distal to neurological level
• Weakness or flaccid paralysis below the level

25. Signs in an Unconcious patients
• Diaphragmatic breathing
• Neurological shock (Low BP & HR)
• Spinal shock - Flaccid areflexia
• Flexed upper limbs (loss of extensor innervation
below C5)
• Responds to pain above the clavicle only
• Priapism – may be incomplete.

26. Signs of spinal injury
• Forehead wounds – think of hyperextension injury
• Localized bruise
• Deformities of spine - Gibbus, feel a step & Priapism
• Beevors sign – tensing the abdomen umbilicus moves
upwards in D10 lesions

27. Prehospital transfer
• Awareness of the crew & by A&E staff
• Modified left lateral position at scene
• Kendrick or Russell’s extrication device
• Scoop stretcher slotted together around the patient
• Agitated patient left alone with hard collar
• Repeated assessment enroute
• Head down if they vomit
• Remove objects from clothes to avoid pressure sores
• Avoid opiates in high lesions
• Avoid oral suction in tetraplegics – vagal reflex

28. Care in A&E
• Careful manual handling especially if unconcious
• Jaw thrust is safer
• Correct gross spinal deformities
• Call the anaesthetist if diaphragmatic paralysis or RR>35
• Use flexible fibreoptic scopes in unstable fractures
• Ryles tube if abdominal distension causes respiratory probl
• Cathetrize to avoid overstretching of detrusor
• IV fluids – paralytic ileus in first 48hrs.
• Passive movements to rule out fractures
• Small iv doses of opiates

29. Assessment
• Document the level of injury
• Rule out other injuries – DPL in abdominal injuries as there is
paralytic ileus and absent peritioneal irritation.
• Associated injuries in dorsal spine fracture are :
- Renal injuries
- Chest and Sternal injuries
- Wide Mediatinum due to fracture haematoma.
- Retroperitoneal injuries

30. Radiology
• Be thorough – Adequacy, Alignment,Bones, Cartilages and
soft tissues and distances
• SCIWORA in kids
• Low threshold for xray in rheumatoid & Ankylosing spond
• Flexion injury common in lower cervical spine
• Extension injury in upper cervical Spine
• Junction of mobile & fixed part are prone to injury eg. C7
T1 & D12 L1.

31. Radiographs in spinal injuries
• Lateral C spine views in diagnostic in 80%
• Complete set of C spine xray are 90% diagnostic
• CT of the c spine is 98% diagnostic
• 22.5* logrolled view for better views of the facets
• 45* view shows the intervertebral foramen & facets

32. Normal Cervical Spine
• Peg & lateral mass distance <2mm and symmetrical
• Peg & arch of atlas distance <2mm in adults < 4mm in kids
• Above C4 the width is <half of the VB width below C4 its
equal to one VB width
• Pseudosubluxation of C2 on C3 is normal in young kids& it
disappears on extension
• C1 and C2 interspinous space <10mm wide
• Distance between occiput and atlas <5mm
• Anterior compression of VB >40% suggest burst fracture

33. Abnormal C spine
• Unilateral facet dislocation < half of the vertebral body
shifted on the lateral view
• Bilateral facet dislocation > half shifted forwards
• Wide interspinous gap is unstable (crush fracture or
subluxation) suggestive of rupture of the posterior cervical
ligament rupture and haematoma formation.
• Severe flexion injury – fractures the anteroinferior margin
of the vertebral body
• Severe extension injury – fractures the anterosuperior
margin of the VB.

34. Emergency treatment
• ABCDE
• Keep warm
• Treat if BP<80mmHg & HR <50bpm
• Spring loaded gardener wells calipers for traction
• H2 Antagonists & Heparin
• Methylprednisolone 30mg/kg iv bolus over 15min
immediately
• 45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in
first 3 hours after the injury.
• 5.4mg/kg/hr for 47hrs if 4 - 8hrs following the injury.

35. Whiplash injury
• Sudden hyperextension and flexion
• Increasing neck pain for the first 24hours
• Associated headache, pain radiating to both shoulders and
paraesthesia in hands
• Reduced lateral flexion
• Anterior longitudinal ligaments are torn causes dysphagia
• Forward flexion against resistance is painful
• 90% are asymptomatic after 2years
• 10% still have pain
• Some still claim money hence the need for proper
documentations.