Spine Trauma

Q: 25 year old man fallen from a ladder, called to A&E as he can’t move his legs

A: ATLS protocol: 3 point C-spine immobilisation, Airway, Breathing with O2, Circulation inc 2 wide bore cannula (bloods, fluids), observations (BP and heart rate could have spinal shock), disability, exposure. Secondary survey.

Definitions

Neurogenic shock is a distributive type of shock resulting in hypotension, occasionally with bradycardia, that is attributed to the disruption of the autonomic pathways within the spinal cord. Hypotension occurs due to decreased systemic vascular resistanceresulting in pooling of blood within the extremities lacking sympathetic tone. Bradycardia results from unopposed vagal activity and has been found to be exacerbated by hypoxia and endobronchial suction. Neurogenic shock can be a potentially devastating complication, leading to organ dysfunction and death if not promptly recognized and treated.

 

Spinal shock was first defined by Whytt in 1750 as a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transection. Reflexes in the spinal cord caudal to the SCI are depressed (hyporeflexia) or absent (areflexia), while those rostral to the SCI remain unaffected. Note that the ‘shock’ in spinal shock does not refer to circulatory collapse, and should not be confused with neurogenic shock, which is life threatening.

 

Hx: Mechanism, time of injury, falls history, PMHx, allergies

Symptoms: Weakness, loss of sensation

Signs: Neurogenic shock, flaccid limbs, reduced power, sensory level, reduced tone on PR, spinal tenderness

 

Management: 3 point c-spine immobilisation, analgesia/antiemetic/bloods/fluids, log roll, ASIA Score documentation, look carefully for other injuries or concurrent spinal fracture (20%), plain film radiographs +/- CT scan +/- MRI.  Asses stability (columns).  Referral to appropriately trained surgeon. Admit, log roll, analgesia, brace if avaliable, bloods, regular neurological re-evealuation and act upon changes, catheterise, discuss VTE prophylaxsis with operative team & TEDs, PPI cover

 

Imaging:

Plain film radiographs of whole spine (20% concomitant fractures)

CT scan indications

fracture on plain film

neurologic deficit in lower extremity

inadequate plain films

MRI to evaluate for

injury to anterior and posterior ligament complex

spinal cord compression by disk or osseous material

cord oedema or hemorrhage

Stability

Denis 3 column system (only moderately reliable)

Anterior Column

Anterior longitudinal ligament

Anterior ⅔ of vertebral body and annulus

Middle Column

Posterior longitudinal ligament

Posterior ⅓ of vertebral body & annulus

Posterior column

Pedicles / facets / flavum / spinous process / posterior ligament complex

 

Unstable:

Two columns injured

Injury to middle column

    • as evidenced by widening of interpedicular distance on AP radiograph
    • loss of height of posterior cortex of vertebral body

Anterior and middle column involvement with disruption of posterior ligament complex

 

Treatment

Consider

Degree of neurologic deficits seen on physical exam

Degree of spinal cord compression and imaging evidence of myelomalacia

Stability

Nonoperative (TLSO Brace)

Most thoracic and thoracolumbar fractures (burst and compression) can be treated nonoperatively when the patient is neurologically intact

Treat in orthosis for 6 to 12 weeks depending on degree of instability

Operative

Indications for surgery

progressive neurologic deficits

myelomalacia seen on MRI

gross spinal instability

posterior osseoligamentous stability compromised

 

Decompression & stabilisation

 

Types

Burst fracture
Definition: Vertebral # with compromise of anterior and middle column (can be unstable)

Mechanism: axial loading with flexion, junc T/L spines fulcrum = vulnerable to burst

Neurologic deficits: canal compromise often caused by retropulsion of bone

    • maximum canal occlusion and neural compression at moment of impact
    • retropulsed fragments resorb over time and usually do not cause progressive neurologic deterioration

Chance fracture (flexion-distraction)

Mechanism: a flexion-distraction injury (seatbelt injury)

    • may be a bony or ligamentous injury (lig more difficult to heal)
    • Middle and posterior colums fail under tension, anterior under compression

Associated injuries: high rate of gastrointestinal injuries (50%)

Lumbar Fracture Dislocation

Definition: Posterior facet fracture-dislocation in the thoracolumbar spine

Mechanism: rotation and shear

Often associated with neurologic deficits, paralysis in upto 80%

Osteoporotic compression fracture

Jefferson Burst

Mechanism: Hyperextension, lateral compression, and axial compression

Peg fracture

Type 1 – Oblique avulsion fx of tip of odontoid (avulsion of alar lig) – Flex / ext vies to rule out atlanto occipital instability

Type 2 – Fx through waist (high nonunion rate – blood supply disrupted)

Type 3 – Fx extends into cancellous body of C2

Hangman’s fracture (Traumatic Spondylolisthesis of Axis)

Bilateral fracture of pars interarticularis (MVA most common)

Mechanism: Hyperextension (causes pars fracture), secondary flexion tears PLL and disc allowing subluxation

30% concomitant c-spine fracture

 

 

Primary Motor Primary Muscles Sensory Reflex
L2,3 Hip flexion

Hip adduction

iliopsoas (lumbar plexus, femoral n.)

hip adductors (obturator n.)

Anterior and inner thigh None
L4 Knee extension (also L3) quadriceps (femoral n.) Lateral thigh, anterior knee, and medial leg Patellar
L5 Ankle dorsiflexion(also L4) tibialis anterior (deep peroneal n.) Lateral leg & dorsal foot None
Foot inversion tibialis posterior (tibial n.)
Toe dorsiflexion EHL (DPN), EDL (DPN)
Hip extension hamstrings (tibial) & gluteus max (inf. gluteal n.)
Hip abduction gluteus medius (sup. gluteal n.)
S1 Foot plantar flexion

Foot eversion

gastroc-soleus (tibial n.)

peroneals (SPN)

Posterior leg Achilles
S2 Toe plantar flexion FHL (tibial n.), FDL (tibial) Plantar foot None
S3,4 Bowel & bladder function bladder Perianal Cremastic

 

 

Muscle Grading System (ASIA)
0 Total paralysis
1 Palpable or visible contraction
2 Active movement, full range of motion, gravity eliminated
3 Active movement, full range of motion, against gravity
4 Active movement, full range of motion, against gravity and provides some resistance
5 Active movement, full range of motion, against gravity and provides normal resistance
NT Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort or contracture.

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