Spine and Spinal Cord tauma Flashcards by K D

Spinal anatomy (specifically where are lamina and pedicles)

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Upper cervical vs lower cervical fractures risk to the spinal cord

Upper cervical fractures (above C3), the spinal canal is much wider, similar to the foramen magnum, so damages to spinal canal may not necessarily translate to damage to the spinal cord

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Difference between in child and adult cervical spine

Differences decline slowly between the age of 8 and 12

more flexible joint capsules and vertebral bodies
flat facet joints
vertebral bodies wedged anteriorly and tend to slide forward with flexion

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Why is the thoracolumbar junction vulnerable

The junction between the inflexible thoracic region and mobile lumbar region

15% of spinal injuries occur here

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Spinal cord anatomy

Originates at the caudal end of the medulla oblongata at the foramen magnum

Ends near L1 as conus medullaris

Below this level becomes cauda equina

Ends as filum terminale

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3 spinal tracts that could be tested clinically

Corticospinal

Spinothalamic

Dorsal column

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Location of the main tracts in the spinal cord

Corticospinal: anterolateral

Spinothalamic: anterolateral

Dorsal columns: posteromedial

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Function of corticospinal tract

Motor

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Function of the spinothalamic tract

Pain and temperature

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The function of the dorsal column

Proprioception, vibration, light touch

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How to test spinothalamic tract clinically

pinprick

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How to test dorsal column clinically

Proprioception in toes

Vibration sensation with tuning fork

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Dermatome level for nipple, xiphisternum, umbilicus and symphysis pubis

Nipple T4

Xiphisternum T8

Umbilicus T10

Pubic symphysis T12

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Complete vs incomplete spinal cord injury

Complete: no sensory or motor function below that level

Incomplete: partial loss of function

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Myotomes of upper limb

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Muscle function grading

0- no movement

1- flickering

2- movement when gravity eliminated

3- against gravity

4- reduced power

5- normal power

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Neurogenic shock definition

Loss of vasomotor tone and sympathetic innervation to heart

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Spinal shock definition

Flaccidity (loss of muscle tone) and loss of reflexes that occur immediately after spinal cord injury

Spasticity follows this after sometime

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Level of injury to cause neurogenic shock

T6 or above

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Mx of neurogenic shock

Fluid replacement (/ r/o haemorrhagic shock)

Vasopressors

Atropine (to inhibit parasympathetic)

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What level of spinal cord injury could lead to hypoventilation?

Paralysis of intercostal muscles (lower cervical/upper thoracic)

Paralysis of diaphragm (C3-C5)

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How to determine the motor level of injury

The most proximal level with a muscle strength grade of 3 or more (can work against gravity)

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Paraplegia vs quadriplegia

Paraplegia: loss of power to both legs (eg by thoracic injury)

Quadriplegia or tetraplegia: loss of power to both legs and arms (eg by cervical injury)

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Central cord syndrome sx

Greater loss of motor in the upper limb than lower limb with varying levels of sensory loss

Mechanism of acquiring central cord syndrome

Typically by hyperextension injury in a patient with pre-existing cervical canal stenosis eg elderly falling forward landing on face

Prognosis of central cord syndrome

Somewhat better than other incomplete injuries

Anterior cord syndrome sx

Paraplegia and bilateral loss of spinothalamic Dorsal column intact

Cause of anterior cord syndrome

Following cord ischaemia

Prognosis of anterior cord syndrome

Poorest prognosis out of incomplete injuries

Brown-Sequard syndrome sx

ipsilateral corticospinal and dorsal column loss contralateral spinothalamic loss

Cause of Brown-Sequard syndrome

Direct penetrating trauma

Atlanto-occipital dislocation mechanism of injury

Severe traumatic flexion and distraction eg shaken baby syndrome

Atlanto-occipital dislocation prognosis

Most die of brainstem destruction and apnoea Or end up with significant neurological impairment (quadriplegia)

Jefferson fracture features

burst fracture of atlas C1 disruption of anterior and posterior rings of C1 lateral displacement of lateral masses

Mechanism of injury for Jefferson's fracture

A large force from above the head or Falling on the head

Investigations for Jefferson fractures

Open mouth view of C1/C2 Axial CT

Initial management of Jefferson fractures

They are unstable fractures need to be stabilised with a cervical collar

C1 rotatory subluxation aka

torticollis (neck rotated to one side)

Causes of C1 rotatory subluxation

Spontaneous Minor or major trauma URTI rheumatoid arthritis

Management of torticollis

Do not force the patient to overcome the rotation, restrict motion in rotated position and refer to ortho

Odontoid process anatomy

Held in the anterior arch of the atlas by transverse ligament

Odontoid peg fracture types

Type 1: the tip of the odontoid Type 2: through the base of dense Type 3: at the base of dense, into the body of axis

Hangman's fracture features

Pars interarticularis fracture (posterior part of axis)

Initial management of hangmans fracture

rigid cervical collar

Most common cervical fracture

Types of thoracic spinal fractures

Anterior wedge compression Burst Chance

Cause of anterior wedge compression

axial loading

Cause of burst fracture

vertical axial compression

Chance fracture features

transverse fracture through vertical body

Mech of injury for a chance fracture

RTA where a passenger was restrained by an improperly placed lap belt causing a flexion about an axis anterior to vertebral column

Management of thoracic fractures

Compression: stable, treated with a rigid brace Burst, chance, fracture-dislocations: unstable, internal fixation

Causes of thoracolumbar junction fractures

Fall from height Restrained drivers who sustain severe flexion

Canadian c spine rule (CCR) use

Alert patients (GCS=15) and stable trauma patient with concern over spinal injury

Criteria for the dangerous mechanism of injury for CCR

Fall from \>1m/5stairs Axial load to head RTA: - \>100km/hr - rollover - ejection Bicycle collision

CCR pathway

NEXUS criteria for imaging for spinal injury

Investigations for ? cervical spine fractures

CT occiput to T1 If not available: Lateral, AP and open mouth odontoid views of occiput to T1

Imaging for patients with cervical tenderness despite having normal initial CT/x-rays

Flexion-extension films or MRI to r/o ligamentous injury

The log-rolling technique for assessment of the spine