A13. Trauma of the spine and spinal cord Flashcards
Prevalence of spinal column trauma:
64/100 000
spinal column trauma Neurological dysfunction is found in how many % of cases
in 10-30% of cases
spinal column trauma can be an injury to either
Vertebral column or spinal cord injury
which part of spine is affected in Trauma of the spine
50% affects cervical spine, 50% lumbar spine
spinal column trauma average age
32 y.o.
Most vulnerable parts of spinal column
are border between rigid and flexible regions (craniocervical,
cervicothoracal,
thoracolumbar zones)
Polytrauma (injury over several regions of spine) occurs in how many %
in 20-25%
Trauma of the spine and spinal cord causes
- motor vehicle accidents,
- falls,
- sports injuries,
- industrial accidents,
- assaults,
- gunshot
- wounds, minor traumas in weakened spine (osteoporosis, osseal tumors
outcome of spinal column trauma depends on
Outcome depends on
* neurological and radiological assessment,
* biomechanical knowledge,
* surgical treatment,
* emergency care
* effective rehabilitation
Spinal cord injuries are they medical emergencies?
yes!
in Spinal cord injuries what is important
- BP must be stabilized and
- oxygenation is important for
adequate blood perfusion to the spinal cord. - Patients must be moved with caution.
symptoms of spinal cord injuries depend on
Symptoms depend on
injury level (spinal cord, conus, epiconus, cauda syndrome, radicular signs
list Spinal cord injuries
- Acute transverse spinal cord injury, spinal shock
- Brown-Séquard syndrome = hemisection
- Anterior cord syndrome
- Central cord syndrome
- Conus medullaris syndrome
- Spinal cord concussion
- Cauda equina syndrome
complete VS incomplete spinal cord injury manifest as
- complete:
*paraplegia
*quadriplegia/tetraplegia - incomplete:
*paraplegia
*tetraplegia/quadriplegia
Acute transverse spinal cord injury, spinal shock - where is the lesion
Lesion of all ascending and descending pathways
→ Motor, sensory, autonomic
dysfunction
Acute transverse spinal cord injury, spinal shock symptoms
● Hypesthesia or anesthesia of all sensory modalities below the lesion
● Paraparesis or quadriparesis (corticospinal tract injury)
in Acute transverse spinal cord injury, spinal shock does Hypesthesia or anesthesia of all sensory modalities occur above or below the lesion
Hypesthesia or anesthesia of all sensory modalities below the lesion
Acute transverse spinal cord injury, spinal shock - what is the acute phase
- flaccid muscle tone,
- areflexia,
- no pyramidal signs (spinal shock)
Acute phase of Acute transverse spinal cord injury, spinal shock
Spinal shock =
* transient depression of all spinal cord functions below level of lesion (also reflexes and autonomic: paralytic ileus,
vasoparalysis with drop in BP,
cardiac shock,
flaccid bowel and bladder → urinary retention and overflow
incontinence).
Usually lasts hours-weeks.
how long does spinal shock last
Usually lasts hours-weeks.
Acute transverse spinal cord injury, spinal shock - what happens after acute phase
- spasticity,
- brisk deep tendon reflexes,
- pyramidal signs,
indicating
upper motoneuron lesion
Brown-Séquard syndrome is mainly due to
= hemisection
● Rare, mainly due to trauma (e.g. gunshot,
stabwound)
Brown-Séquard syndrome symptoms
- Ipsilateral proprioceptive sensory loss (proprioceptive tract)
- weakness (corticospinal tract) with contralateral loss of pain and temperature (spinothalamic tract)
Anterior cord syndrome is similar to which other syndrome
Similar to anterior spinal artery syndrome
cause of Anterior cord syndrome
Either due to
* compression of anterior part of
spinal cord
or
* the interruption of blood supply
from the anterior spinal artery
Anterior cord syndrome symptoms
● Below the lesion:
* Loss of motor function, pain and temperature sensation
Central cord syndrome is often associated with
flexion type of injuries to cervical spine
Central cord syndrome symptoms
● Weakness of upper limbs and some weakness of lower limbs
● Spinothalamic sensory loss
with intact proprioceptive sensation is also typical
Conus medullaris syndrome what is it
● Sensory loss (numbness) in the perianal region and inner thighs (saddle anesthesia)
and
loss of bladder control
(retention with overflow incontinence) without leg weakness
or diminished stretch reflexes
Spinal cord concussion is it permanent neurologic deficit
● No permanent structural damage or neurological deficit
Spinal cord concussion symptoms
- Temporary neurological deficit, similar to cerebral concussion
- No permanent structural damage or neurological deficit
Cauda equina syndrome symptoms
- Radicular pain in several dermatomes,
- flaccid paralysis of lower limbs
- with loss of deep tendon reflexes and
- overflow incontinence
list Vertebral fractures
- Jefferson’s fracture - Simultaneous fracture of anterior and posterior arches of C1
- Dens fracture (C2)
- Hangman’s fracture (C2-axis trauma)
what is Jefferson’s fracture
Simultaneous fracture of anterior and posterior arches of C1
* Often from axial impact of head, when head is pushed towards the spine.
* The atlas is caught between the occipital condyles and its arches break.
not bold ones will be mentioned in other questions
when does Jefferson’s fracture occur
- Often from axial impact of head, when head is pushed towards the spine.
- The atlas is caught between the occipital condyles and its arches break.
what happens to the atlas in Jefferson’s fracture
Often from axial impact of head, when head is pushed
towards the spine.
The atlas is caught between the occipital condyles and its arches break.
does Jefferson’s fracture involve one or multiple arches?
both
* May be fracture of one or multiple (56%) arches
Jefferson’s fracture symptoms
- Stiff neck,
- pain when moving neck,
- no neurological signs,
- may have structural instability
Dens fracture is common in which age
Common in elderly
Dens fracture is a fracture of which vertebra
(C2)
Dens fracture is usually due to
motor vehicle accidents
is Dens fracture fatal and why
Fatal in 25-40% due to medulla compression
fatal complication of Dens fracture
Fatal in 25-40% due to medulla compression
how do C2 fractures happen
either be from the
* dens breaking off
* or body of C2 breaking
Dens fracture symptoms
- Usually causes structural instability that needs stabilization
- Neck pain radiating to occipital region (worse with neck movements), typically the patient will hold their head
in Dens fracture what happen if alar ligament tears
Tear of alar ligaments may occur without a fracture
→
Atlanto-axial subluxation and
dislocation
can Tear of alar ligaments occur without a fracture
YES
may occur without a fracture
Hangman’s fracture epidemiology
7% of cervical fractures
Hangman’s fracture occurs at which vertebra
C2-axis trauma
Body of C1 slides forward on body of C2 → Fracture of C2 arches
when does Hangman’s fracture occur
during hanging
Hangman’s fracture can be similar to what fracture
Can also have similar fracture with spinal cord injury from motor vehicle accidents where
the neck is suddenly hyperextended
AO (Association for Osteosynthesis) classification of subaxial and thoracolumbar fractures- types
- Type A (15% of subaxial cervical ,⅔ of thoracolumbar)
- Type B (50% of subaxial cervical)
- Type C (35% subaxial cervical)
AO (Association for Osteosynthesis) classification of subaxial and thora
Type A subaxial and thoracolumbar fractures fracture location
(15% of subaxial cervical, ⅔ of thoracolumbar)
AO (Association for Osteosynthesis) classification of subaxial and thora
what happens in Type A fracture
- Axial compressive forces → Vertebral compression and a burst fracture → Segment shrinkage.
- When force strikes the spine from the vertical
direction (e.g. diving into shallow water, fallow on the head in motor vehicle accidents).
Half are associated with severe neurological deficit
below the level of the injury with predominantly anterior spinal cord symptoms.
AO (Association for Osteosynthesis) classification of subaxial and thora
symptoms in Type A fracture
- Half are associated with severe neurological deficit
below the level of the injury - with predominantly anterior spinal cord symptoms.
AO (Association for Osteosynthesis) classification of subaxial and thora
direction of force in Type A fracture
When force strikes the spine from the vertical
direction (e.g. diving into shallow water, fallow on the head in motor vehicle accidents).
AO (Association for Osteosynthesis) classification of subaxial and thora
Type B fracture location
50% of subaxial
cervical)
AO (Association for Osteosynthesis) classification of subaxial and thora
how does Type B fracture occurs
- Distractive forces (flexion-extension) → Tear of parts of the segment and segment elongation.
E.g. whiplash injury in motor vehicle accidents
where cervical spine suffers hyperflexion followed by hyperextension.
AO (Association for Osteosynthesis) classification of subaxial and thora
type B fracture are often associated with
- central cord syndrome and
- hematomyelia (the presence of a well-defined focus of hemorrhage within the spinal cord itself)
what is central cord syndrome
injury to the central region of the spinal cord (central corticospinal tracts and decussating fibers of the lateral spinothalamic tract)
(most common incomplete spinal cord injury )
typically affects the cervical cord.
ETIOLOGY OF central cord syndrome
- hyperextension of the neck,
- syringomyelia,
- intramedullary spinal cord tumors
- Degenerative spine disease
- Cervical spondylosis
- Traumatic disk herniation
AO (Association for Osteosynthesis) classification of subaxial and thora
Type C
fracture location
(35% subaxial
cervical)
Type C fractures are caused by
by shearing forces → Either shrinkage or elongation of the segment.
Degree of spine instability (and risk of neurological deficit) for AO (Association for Osteosynthesis) classification of subaxial and thoracolumbar fractures
spine instability increases A-C.
C most unstable
According to the classification, List three principles of surgical intervention in spinal trauma:
a. Reposition
b. Decompression
c. Stabilization
Acute spinal injury is often accompanied by
severe neurological deficits
For spinal cord compression,
what does functional injury depends on
functional injury depends on the
* time of surgical intervention.
how can Secondary effects of the injury be
prevented
with high dose (1-2g) i.v. corticosteroids until surgery.
