Anterior vertebral body is
the main weight-bearing column. Ant & post longitudinal ligs
hold together vertebral column & discs.
Posterolateral pedicles support
laminae which together
house the vertebral canal. Facet jts, interspinous ligs, and paraspinal muscles all help
stabilise the spine.
Ends at L1 in an adult.
- below this the cauda equina
is more resistant to injury.
Only 3 tracts can be readily assessed clinically: 1. Corticospinal:
Motor supply to same side.
- test by voluntary movement or response to pain. 2. Spinothalamic:
Pain and temp sense from opposite side.
- test by pinprick and light touch. 3. Posterior columns:
Position sense (proprioception), vibration and some light-touch from
- test by position sense or vibration.
Used to determine level of spinal injury. Sensory level: lowest
dermatome at which normal sensory fx occurs - can differ by side.
- C1-4 are somewhat cariable and not commonly needed.
- however C2-4 supply the 'cervical cape' over the pectoralis via
C5 = deltoid area
C6 = thumb
C7 = middle finger
C8 = little finger
T4 = nipple
T8 = xiphisternum
T10 = umbilicus
T12 = symphysis
L4 = medial aspect of leg
L5 = space b/n toes 1-2.
S1 = lateral border of foot
S3 = ischial tuberosity area
S4-5 = perianal.
C-spine is more mobile
and more prone to injury.
- see C-spine card for more
detail. T-spine is less mobile and
supported by rib cage, hence injury much lower and more likely
simple compression fractures.
- however when #-dislocation does occur, complete neurological
injury more likely due to narrow thoracic canal dimensions. Thoracolumbar jx is a
fulcrum point and more vulnerable to injury.
Impairment of descending sympathetic
Loss of vasomotor tone +/- sympathetics to heart.
--> hypotension, bradycardia or failure to enter compensatory
BP will not respond to fluid alone
--> judicious use of vasopressors
--> perfusion may be ok with a low BP
--> atropine may be needed for bradycardia
Spinal Shock Flaccidity / loss of reflexes
in spinal cord injury.
Although may appear completely functionless, all areas may not be
- duration of this state variable.
Other systemic effects
Paralysis of intercostal muscles.
C3,4,5 damage may cause diaphragmatic paralysis.
Loss of pain sense may mask injury to eg abdomen.
The most caudal segement
with normal function on
- sometimes just a sensory or
motor level (power at least
- there may be a lower zone of
partial preservation. Bony level refers to site
of bone damage (less important).
- may not agree with neurological level, especially more caudally.
Quadraplegia results from injuries to first 8 segments
Paraplegia to lesion below T1.
Severity Complete when no sensory /
motor below a certain level.
- deep tendon reflexes or sacral reflexes (eg anal wink /
bulbocavernosus) may be preserved. Incomplete when any fx remains.
- significantly better prognosis for recovery.
- may include any sensation / position sense / movement.
- perianal sensation (sacral
sparing) may be the only sign of residual function: test by
sense in perianal region or voluntary contraction of the rectal
Central Cord Syndrome Usually hyperextension in preexisting cervical canal
stenosis. - with or without C-spine # / dislocation.
--> vascular compromise in distribution of anterior spinal
--> ischaemia of central portion of cord, where cervical segments
Disproportionately greater motor loss in upper vs lowever
extremities. - varying degree of sensory loss.
Prognosis relatively good: legs usually reover first, then bladder,
then arms, then hands.
Anterior Cord Syndrome
Infarction in area supplied by anterior spinal artery.
Paraplegia, dissociated loss of pain/temp sensation.
- posterior column preserved (position, vibration, deep pressure).
Pure: ipsilateral motor loss (corticospinal) and position sense loss
(posterior column), contralateral dissociated sensory loss one or
two levels lower (spinothalamics).
Unless by direct penetrating trauma recovery is seen.
Fractures, #-dislocations, spinal cord injury w/out radiographic
- each may be stable or unstable.
- deciding this is not always simple
Consider all x-ray evident and all neurologically injured pts to be
unstable until consultation.
Thoracolumbar Jx #s
High incidence at this site - relative immobility of thoracic vs
Combo of acute hyperflexion & rotation.
- eg fall from a height, restrained drivers.
- bladder and bowel, lower limb.
Treat all pts with altered CGS, multisystem injury, palpable gap /
tenderness in TL-spine with spinal protection until Ap & lat
- particularly vulnerable to log-rolling.
Similar to thoracolumbar #s
- but less neurologic deficits
Chance #s Distraction applied in flexion, eg a seat belt.
Splitting injury, begins posteriorly, proceeds through vertebral
body or disk.
Possibly associated with retroperitoneal / abdo visceral injuries.
See C-spine card.
AP XR is standard.
- better definition than lateral.
Subsequent films as required.
CT is useful for bony detail.
- very useful for assessing degree of canal compromise.
AP, lateral and CT through suspect areas detects >99% of unstable
Introduction Excessive manipulation and
inadequate immobilisation can cause additional neurological injury.
-5% of pts experience worsening of symptoms after reaching the ED
due to ischaemia or oedema and failure to immobilise properly. Protect the spine - then
proper evaluation and exclusion of injury may be safely
deferred. Need immobilisation above and below the suspected
Do not try to reduce an obvious deformity.
Bring to neutral position and maintain. - however attempts to align
the spine for immobilisation on a backboard are not recommended if
they cause pain. Semirigid collars do not
assure complete stabilisation of c-spine. C-spine injury requires:
continous immobilisation, semirigid cervical collar, backboard, tape
- maintain neck in neutral position if intubation likely.
Long spine boards are prefered. Agitated pts can be
- seek the cause
- if sedation is required, use short acting reversible agents and be
an experienced clinician.
Be ever alert for chance of decubitus
- log-roll as part of secondary survey, the board is often removed
at this stage.
- if not feasible to remove spine board as quickly as possible
log-roll every 2 hrs to reduce risk of ulcers.
- occiput and sacrum esp at risk.
1) Neurology (eg paraplegia, level of sensory loss) is presumptive
evidence of spine injury
2) If awake, alert and non-tender along entire spine - inspection
and palpation virtually excludes injury.
- XRs may not be necessary
3) If decreased consciousness, intoxication or spine pain /
- AP&lat of entire spin with
- if XR inconclusive spine must remain immobilised while axial 3mm
CT performed on suspicious areas.
- then protection may be discontinued.
- note also the danger of prolonged immobilisation on a spinal
4) Consult if spine injury suspected / detected.
Remember pts in hypovolaemic shock will be tachycardic.
Those in neurogenic shock will be bradycardic / normal HR.
If BP does not improve with fluid challenge, judicious vasopressors
- penylephrine hydrochloride, dopamine and norepinephrine
Overzealous fluids will cause pulmonary oedema in spinal pts.
Insert a catheter.
Methylprednisolone is given in Nth America.
30mg/kg in first 15mins.
Then 5.4 mg/kg/hr for next 23 hrs.
If administered in first 3 hrs of injury, infusion should be given
No benefit from this or other steroid if started at >8hrs.
ASAP to definitive care after discussing with relevant specialist.
Be prepared for respiratory care if injury above C6.
· Primary spinal cord
injury: occurs at the time of injury
· Secondary spinal
cord injury: Occurs due to hypoxia (loss airway, failure of
ventilation), hypoperfusion (neurogenic shock and haemorrhage),
oedema and mechanical disturbance (failure of immobilization).
· A: airway control
maintaining C-spine in-line immobilization
B: High cervical
injuries (above C3-C5) compromising phrenic and interocostal
function leading to ventilatory failure.
· C: cervical and
high thoracic injuries lead to neurogenic shock. Treated with
judicious fluids and use of pressors (phenylyephrine) and
atropine (overcome bradycardia).
· A thoracic
dissection can mimic spinal cord injury as cord ischaemia occurs
at the watershed area at T4 between the vertebral and radical
· C-spine film –
should consist of AP/LAT/Odontiod. The C7/T1 junction should be
visualized during the cross-table C-spine.
· It is rare to miss
significant injuries in an adequately performed and interpreted
set of plain x-rays.
· Neurological signs
and symptoms in the setting of a cervical spine injury warrant
further evaluation (SCIWORA)
30% in pediatric with spinal cord injury
5% in adult with spinal cord injury
stenosis or hyperflexion or hyperextension injury may result in
spinal cord injury without radiological evidence
without neurological deficit, who are not intoxicated have no
distracting injury, are alert and non-confused have no neck or
midline pain or tenderness have a 99.8% probability of no
cervical spine injury and require no X-rays.
tissue space should be
1/3 of the width of C3
equal to the width of C6 at that level
(rule: C2-7 and C7-11).
Back of C1 arch to
front of odontiod peg <3mm.
alignment, evaluate each vertebral body for fracture. If
vertebra are offset <1/2 width unilateral facet joint
dislocation, >1/2 offest indicates bilateral facet joint
Lateral margin of
C1 should not overlap C2 (if it does think of Jefferson # -
burst # C1). If the total overhang of the lateral masses of C1
on C2 exceeds 7mm think that there may also be a disruption of
the transverse ligament.
— Soft tissue
C2-C5 £ 5mm
In alert patients
with normal plain films and persistent symptoms – supervised
flexion and extension views can be taken or CT/MRI performed.
· Special views
· CT – more sensitive
than plain x-ray and can be done without moving the patient.
They are indicated if:
— C1-3 – Not
— C7 / T1 - Not
— Abnormal XR
— Coma / intubated
— Persistent pain
(Spinal Cord Injury WithOut Radiological
Abnormality) – signs or symptoms of spinal cord injury
without radiographic abnormality. First described in children,
but probably less common in adults. It occurs in about 40% of spinal
cord injuries in children <9years and <5% of spinal cord
injuries in adults.
· The main value of
MRI is in patients with a negative CT who are still suspected of
having a traumatic spinal cord injury from ligament disruption, disc protrusion or
epidural haematoma. Limitations – cannot be easily used
with metallic implants or when intensive monitoring is required.
· Spinal shockdifferentiate from neurogenic shock associated with
spinal cord injury
shock is a transient absence of all cord functions below the
level of injury
· Neurogenic shock is
a hypotension secondary to cervical or upper thoracic
complete spinal cord injury
Treatment with both A and B vaso-pressers to improve BP
· For patients with
fracture dislocations – closed reduction in emergency room is
safe and effective with improved neurological outcome in the
presence of spinal cord injury and may decrease the incidence
and severity of pulmonary insufficiency.
head tongs can be used to achieve closed reduction of
cervical fracture dislocations.
· This is performed
under controlled conditions with fluoroscopy, monitoring of
vital signs and neurological examination.
· There is a
sequential increase in the weights applied to the head tongs
until reduction is achieved.
· An initial weight
of 10 ponds is applied and weight is increased in 5 pound
increments and a lateral x-ray taken until reduction is
skull fracture where pins of tongs are to be applied and
distractive type injuries.
stabilization is required in the post-injury phase.
Indication for Acute Surgery:
spinal cord injuries < 24 hours – restoration of
spinal cord anatomy will not improve function after 24 hours thus is not performed.
with complete injuries > 24 hours old or clinically unstable
patients should not undergo surgery. <2% will recover
instability can be treated for early mobilization and
with incomplete injuries and those with neurological
deterioration may undergo acute surgery
spinal cord injuries – there is some sensory or motor function
below the level of injury (>75% may recover)
· Restoration of
anatomy and decompression of the cord may improve function
· Patterns of
incomplete injury: anterior cord syndrome, hemi-section, central
· Incomplete injuries
believed to be stable or unstable only in one column can be
managed by immobilizationonly (halo brace cervical spine and molded orthosis
for T and L spine) unless neurological deterioration occurs.
· Injuries affecting
two or more columns are treated with internal fixation.
What is the bulbocavernosus
· Monitoring anal
sphincter tone in response to squeezing the glans penis or
tugging on urinary catheter.
· Lack of motor or
sensory function after the reflex has returned indicates
complete spinal cord injury
Special Type of Spinal fractures:
burst # of C1
Odontoid Fracture (C2):
Type Ioccur in the dens
Type IIoccurs across the base of dens where it joins the body of
Type IIIoccurs extension into the body of C2
bilateral # through the
pedicles of C2 causing by hyper-extension (i.e. judicial
Often associated with neurological deficit
common in T12-L2 as the Seat-belt injury. Compression # in
anterior column then extending to posterior aspect of vertebrate
Often associated with intra-abdominal injury
Special Type of Neurological Deficit
Complete Transverse Myelopathy:
All function below the
injury is lost from transaction, contusion, or stretching of
Anterior Cord Syndrome
Anterior 2/3 of cord
(distribution of anterior spinal artery). Motor/pain/temperature gone
Central Cord Syndrome
Injury in central
Common in pt with
pre-existing spinal problem
Motor deficit worse
than sensory deficit
deficit worse than lower extremities
Common in penetrating injury than blunt
Injury to half of
Unilateral disc herniation or unilateral lacerating half
motor/touch/proprioception gone(tract cross in brainstem)
pain/temperature gone (tract cross in the near cord
Thoracic Aortic Dissection
T4 is the watershed
zone for vertebrate arterial and aortic radicular artery.
-NASCIS II and III National acute
spinal cord injury study
-Controversial area: outcome (return of neuro
function is no difference and pt LOS is quicker in treated
-No value after 8 hours of injury
-Needs prednisone 30mg/kg loading dose (2100mg for
70kg) then 5.4mg/kg/hr for 23 hours (40mg/hr).
-If treated within 3 hours of injury, no further
-If treated 3-8 hours of injury, may improve outcome
if extending treatment to 48 hrs