Anatomy of the Cord and Cauda

*Spinal cord from foramen magnum to L1Conus at L1 for bowel and bladder (nervi

eriganties S1-S5)*L1 to S1 roots start innervation of lower

extremities*Thoracic blood supply to the cord starts

at T10-T12 (artery of Adamkowitz)*Lumbar blood supply is abundant

Physiological Anatomy of the Thoracic Spine

Facets lie in the frontal plane- allowing rotation

Ribs resist rotation and add stiffness in lateral rotation

Kyphosis of the T spine loads the anterior column

Lower 2 vertebra have floating ribs and no costotransverse articulations

Canal size in thoracic spine relatively small

Physiological Anatomy of the Lumbar Spine

Large discs allow more ROMFacets prevent rotation

Spinal canal widerLordosis loads the facets

Thoracolumbar JunctionThoracic spine stiffer in flexion (ribs) than lumbar

spine (stress riser)Lowest 2 thoracic vertebra have less extrinsic

stability secondary to changes in facet orientation and floating ribs (T11-12 have frontal facets but no conjoined ribs to stabilize, therefore less rotational resistance)

In pure axial loading, thoracic spine deforms into kyphosis and lumbar spine into lordosis leaving the transition vertebra exposed to pure compression

Force distributed over 10 thoracic and 4 lumbar vertebra is withstood only by 2 vertebra at the thoracolumbar junction

Mechanisms of InjuryHow much energy was imparted into the

individual (fall from height vs fall from level skiing vs ejection from car)

What was the loading force (impact onto buttocks vs impact onto flexed neck vs impact from object)

What was the force trajectory (beam impact vs restrained MVA vs collision with tree)

What was the quality of the tissue of the recipient to resist force (young adult vs senior/ preexisting pathology)

CAUSES OF SCI

Patient History

Loss of consciousnessLoss of motor strength (temp or

present)Sensory changes (temp or present)

Incontinence (at scene vs current)Localized pain to other areas

Dyspnea (pneumothorax)Past medical history

Patient Examination

ABCs first, then trauma examinationMotor strength L1-S1(for suspected

thoracolumbar injury)Sensory C4-S3

Reflexes (hyperreflexia asso. with preexisting myelopathy)

Rectal exam (sensory, tone and contraction) (missed conus injury)

Bulbocavernosis (if necessary)

STAGESStage of spinal shock (Flaccid Stage)

sensation and motor power localized below the vertical height of the lesion are lost. This stage lasts for 2 to 3 weeks in humans, and hours to days in other animals.

Stage of recovery (spastic stage)after a period typically ranging from 2 to 3

weeks of injury, the nerves partially recover, and the return of segmental reflexes produce paraplegia-in-flexion.

.

SYMPTOMS

The vertical location of the injury

In general, injuries that are higher in our spinal cord produce more paralysis .

The severity of the injury.(T S section)

Spinal cord injuries are classified as partial or complete, depending on how much of the cord width is damaged .

Treatment of Neurologic Injury

Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours

Only for central injuries- not peripheral nerve injuries (conus is central injury)

Mutiple Spinal Injuries

3 patternsWatch out for

distracting injuries10% of patients

can have other spinal injuries

Severity of trauma- splenic/ liver and vessel injury

Classification System

Holdsworth 2 column theoryDenis 3 column theory

Classification of Injuries Simple Compression (1-2 column injury)

Stable burst (2-3 column injury)Unstable burst (3 column injury)

Flexion distraction (2 nonconjoined columns)Chance (3 column failure all in tension)

Fracture dislocation (3 column injury)Pure Dislocation (rare) (3 column injury)

Pathological (any and all)Insufficiency (any and all)

Multiple contiguous fractures (nly 1-2 columns)

Compression Fractures

Only anterior column injuryMiddle? and post. OK

Ant. column less than 30%No more than 10 deg kyphosis

No neuro injury

Flexion distractionEasy to miss-

may look benignAnterior column

> 50% crushedMiddle column

mainly intactSignificant

spinous process widening

Unstable

Stable Burst

Both ant and middle column involvement

Minimal kyphosisNo neuro

involvementNo laminar

fracture

Unstable Burst

3 column involvement

Possible neuro involvement

Severe communition

Significant pedicle widening

Look for laminar fracture (asso. with root entrapment)

Chance FracturesOld “Seatbelt injuries”

Center of rotation is anterior to ALL

May be “bony” chance or purely ligamentous

Normally neuro intact “Bony” stable,

ligamentous unstable even though all are 3 column injuries

Fracture Dislocations

Translation in lower lumbar spine may be developmental (only L3-S1 spondylolysthesis)

Always abnormal in thoracic spine (ribs fix)

UnstableNormally- neuro deficit

Can be hidden at mid thoracic spine

3 column injury

Pathological Fractures

Normally in patient with history of CA

May be hard to distinguish from insufficiency or osteoporosis fracture

May be multiple levelsFracture out of

proportion to force of trauma

Suspicion calls for MRIand ?Bone scan

Insufficiency Osteoporosis Fractures

Normally in elderly females

Osteopenia/malaciaBones have “washed

out” appearance Minimal force vectors

Multiple levels (normally)

Kyphosis greater than 70 degrees may need surgery

?Vertebroplasty treatment

So how do you read the films?

Look at alignment of vertebraOn AP- measure pedicle distance and look

for both SP splaying and laminar fracturesMeasure kyphosis from intact endplates

Measure anterior and middle column heightLook for retropulsion

High index of suspicion for other fractures

Look at alignment

Look at how the anterior and posterior aspects of the body line up

Spinous Process Splaying

Indicative of either chance (stable) or flexion distraction (unstable) injury

Laminar Split

Associated with burst or flex-distraction fractures

Look on exam for root injuries (they become entrapped in lamina)

Possible association with dural tear

Measure Kyphosis

Measure from closest intact endplates

Measure Ant. and Middle Column Heights

Compare with vertebra above and below

Measure pedicle distances

Compare to vertebra adjacent to injured one

Anterior Column Fx Treatment Simple compressions can be placed in a Jewett or TLSO off the shelf brace and discharged from the ED or office as long as pain is controlled, fracture is stable with new standing x-rays in brace and they don’t have an ileus. Cannot treat fractures above T6 without cervical extension

Stable Bursts and Lateral Compression Fractures Admit- pain mgmt and

neuro checksBrace management -

Off the shelf TLSO for simple compressions greater than 30% and lateral compressions, Custom TLSO for unusual body habitis, severe bursts and pts that need stability testing. CASH for insufficiency Fxs

Complications from Fracture Pneumothorax (thoracic Fxs with asso rib Fxs)/

Ileus (30-60%)Splenic, liver and vessel injury (mechanism of

injury)DVT/PE

DecubitisUTI

PneumoniaRenal failure (hydronephrosis from cauda

equina involvement)

Stress Testing

Fracture that may be unstable

Bed rest until ambulance arrives

X Rays supine/ 45deg/ 90 deg/ upright

Stop if neuro involvement, sig. Pain increase or sig. Increased kyphosis

45 degrees vs upright

Surgical Indications

Neurological InvolvementFlexion distraction injury

Greater than 50% canal compromise with >15 degrees kyphosis

>25 degrees kyphosisFailure of stress testing

(severe pain, angulation above 25 degrees, neuro symptoms)

Fracture dislocationsSoft tissue “chance” fractures

Time to healing

Most non-surgical fractures heal within 12 weeks

Back support with braces(types)on whenever .patient upright

When healed- 4 weeks of PT for deconditioning

Residuals of barometric sensitive discomfort and occasionally problems with lifting

10 % may need to go on to surgery from instability pain

NURSING BEDS

Clinitron Bed Tilt Bed

ROTAREST BED

Thank You