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SPINAL CORD INJURIES. M.R.EHSAEI M.D ASSOCIATE PROFESSOR OF NEUROSURGERY. Anatomy of spine. Complete spine contains 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal Spinal cord protection Ligaments. Ligaments of spine. Vertebra (29) 7 cervical, 12 thoracic,

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spinal cord injuries




anatomy of spine
Anatomy of spine
  • Complete spine contains
    • 7 cervical
    • 12 thoracic
    • 5 lumbar
    • 5 sacral
    • 4 coccygeal
  • Spinal cord protection
  • Ligaments

Vertebra (29)

7 cervical, 12 thoracic,

5 lumbar, 5 sacral

Conus medullaris at L1-2


31 spinal cord segments

8 cervical, 12 thoracic,

5 lumbar, 5 sacral, and

1 coccygeal

C1 dorsal roots missing

in some


Cerebrospinal fluid


50-200 mm H2O pressure

0-10 WBC


< 45 mg/100 ml protein

glucose 2/3 blood level

50-80 mg/100 ml

Spinal tap done at L3-L4

Dural sac ends at vert. S1-S2

cervical spine
Cervical Spine
  • C1 – Atlas
  • C2 – Axis
  • Vertebral canal – space for spinal cord
  • Intervertebral foramen – nerves exit from canal
anatomy of spine1
Anatomy of spine
  • Anterior column
      • Half of Vertebral bodies and intervertebral disc
      • Anterior longitudinal ligament
  • Middle column
      • Half of Vertebral bodies and intervertebral disc
      • posterior longitudinal ligament
  • Posterior column
      • Pedicles, facet joints, lamina
      • Supraspnious, interspinous, infraspinous ligaments


Car Crashes: 83%

Motorcycle incidents: 10%

Bicycle accidents: 3%

Medical/Surgical Complications: 38%

Hit by falling Object: 30%

Pedestrian: 22%

Gunshot: 92%

Personal Contact: 6%

Diving: 55%

Snow skiing: 8%

Surfing: 6%

Source: National Spinal Cord Injury Statistical Center

  • Spinal injury
    • Motor vehicle crashes :41%
    • Falling down :21%
    • Sporting activity:8%
    • Human violence:22%
    • Others:8%
  • Average age : 34yrs
  • M:F = 4:1
  • Approx. 100,000 new cases/year, 80% male. Age group most commonly injured: 16-30 years (43%) and 31-45 (28%).
  • Although Vehicle is the leading cause overall, Falls become the leading cause in people over 60 years.
spinal cord injuries1
Spinal Cord Injuries
  • Traumatic injury of vertebral and neural tissues due to compressing, pulling or shearing forces
  • Most common locations: cervical (1&2), cervical (4-7), and 12th thoracic – 2nd lumbar vertebrae
    • Locations reflect most mobile portions of vertebral column and the locations where the spinal cord occupies most the the vertebral canal
spinal cord injuries2
Spinal Cord Injuries
  • Vertebral injury can occur due to fracture, dislocation, or both.
  • Within minutes after injury, hemorrhages appear in the central gray matter, pia, and arachnoid.
  • Local hemorrhages reduce vascular perfusion
general symptoms signs
General Symptoms & Signs :
  • Pain &Tenderness
  • Skin abrasions or contusions
  • Subcutaneous Hematoma
  • Muscle Spasm
  • Cripitation in Touch
  • SpinalDeformity
neurological exam
Neurological Exam:
  • Detection & Documentation :
    • Sensory Level
    • Posterior Column function
    • Sacral Sensory Sparing
    • Muscle Weakness (0 - 5 )
    • Pathological Reflex (BCR & Babinski)
    • Rectal Exam for Tone & cotracture
neurological evaluation
Neurological evaluation:
  • Complete inj.:no motor or sensory function below the zone of inj.
  • Incomplete inj.:partial preservation of motor or sensory function below the zone of inj.
neurological evaluation cervical inj
Neurological evaluation:cervical inj.
  • Incomplete inj.:
        • Ant cord syn.
        • Central cord syn.
        • Brown-sequard syn.
        • Post.cord syn.
  • Spinal shock:
        • hypotension without tachycardia (motor,sensory,and reflexes are absent but cannot determine complete inj.until bulbocavernosus or other reflexes return within 24 houres.)
incomplete spinal cord lesions
Incomplete Spinal Cord Lesions
  • The anterior cord syndrome
    • cervical flexion injuries causing cord contusion
    • protrusion of a bony fragment or herniated intervertebral disk into the spinal canal
    • laceration or thrombosis of the anterior spinal artery
    • rarely, systemic embolization or prolonged cross-clamping of the aorta during resuscitation or surgery
incomplete spinal cord lesions1
Incomplete Spinal Cord Lesions
  • central cord syndrome (m/c)
    • affects the central gray matter and the most central portions of the pyramidal and spinothalamic tracts
    • a greater neurologic deficit in the upper extremities than in the lower extremities
incomplete spinal cord lesions2
Incomplete Spinal Cord Lesions
  • The Brown-Séquard syndrome, or hemisection of the spinal cord
    • a penetrating lesion such as a gunshot or knife wound
    • ipsilateral motor paralysis and contralateral sensory hypesthesia distal to the level of injury
neurologic status frankel scale
Neurologic status : frankel scale
  • a) no motor or sensory function
  • b) sensation but no motor function
  • c) motor function present but useless
  • d) motor function present but useful
  • e) normal motor and sensory
neurologic exam cervical inj
Neurologic exam: cervical inj.
  • C4(spont.breathing),C5(deltoids and biceps) C6(wrist ext.),C7(triceps and wrist ext.),C8 (finger flex.),T1(intrinsics).
  • Sensory:C5(upper outer arm),C6(thumb),C7 (long finger),C8(little finger),T1(medial forearm).
prognosis of spinal cord inj
Prognosis of spinal cord inj.:
  • Complete inj: usually remains complete,but one or two level recovery is expected.
  • Incomplete inj.:have potential for significan t recovery, particlarly in bronwn-sequard and central cord syn.
prognosis of spinal cord inj1
Prognosis of spinal cord inj.:
  • Gunshot wound to the spine with spinal cord inj.carry a poor prognosis for recovery.
  • Spinal cord recovery is better if bony impingment is removed for incomplete type.
  • Patients with congenital C1-C2 instability and congenital stenosis have higher incidence of spinal cord inj.
prognosis of spinal cord inj2
Prognosis of spinal cord inj.:
  • Patient with ankylosing spondylitis often sustain unstable three-column inj.,even with minor trauma.
  • High dose corticosteroid is administrated early to patient within 8 hours of inj. to improve the prognosis.
radiological studies
  • Plain x-ray:

Ap--LAT--Open mouth—Oblique- Pillar view--Stretch test--Flexion/Extension view

  • Tomography
  • C.T scan :best modality for bony lesion.
  • Myelography
  • C.T myelography
  • M.R.I: best for soft tissue and give prognosis after inj.
upper cervical inj
Upper cervical inj.
  • occipital condylar fx.
  • occiput-c1 dislocation.
  • C1-C2 subluxation.
  • fracture of C1.
  • frature of odontoid.
  • fracture through the pedicle of C2.
occipital condylar fx
Occipital condylar fx.
  • diagnosis with tomogram or C.T scan.
  • lig.inj, I.c.hematoma,and neurological deficit may accompany this inj.
  • treatment:
        • usually rigid orthosis or halo vest for 3 m.
        • flex/ext film is obtained at 3 m.
        • occiput to c2 fusion if resultant instability.

occiput-c1 dislocation:

# flex/ext force on the head.

#disruption of all lig.

#unstable and always fatal.

#treatment:occiput-c1 fusion.

c1 c2 subluxation
C1-C2 subluxation:
  • Rupture of transverse lig.
    • Atlantodens interval:
        • 3-5mm indicate rupture of transverse lig.
        • >7-8mm indicate all lig.disruption.
        • >10mm causes spinal cord compression.
    • Treatment:
        • if instability 3-5mm==>halo for 2-3 m then dynamic study repeated.if instability >4mm then needs fusion c1-c2.
          • if instability >5mm then early fusion c1-c2.
c1 c2 subluxation1
C1-C2 subluxation:
  • Atlantoaxial rotatory fixation: the head is tilted toward the side of fixation and the chin and c2 spinous process is pointed toward the opposite direction.
      • Type 1: rotatory fixation with no ant. displacement.
      • Type 2: rotatory fixation with 3-5mmant.displacem.
      • type3: rotatory fixation with>5mm ant displacement
      • Type4:rotatory fixation with post.displacement.
    • tratment: reduction&c1-c2 fusion if unstable.
stable upper cervical injuries
Stable Upper cervical Injuries:
  • Atlas fractures:
    • ant. arch fx.
    • post. arch fx.
    • lat. mass fx.with less displacement.
  • Axis fractures:
    • type 1 odontoid fx.
    • hangman fx.without angulation.
fracture of c1
Fracture of C1:
  • Axial loading usually with breaks at two sites.
  • >7mm widening of lat.mass==>trnsverse lig.rupture .==>first immobilization with hallo for 2-3m and C1-C2 fusion may be performed if instability is greater than 5mm.
fractures of odontoid
Fractures of odontoid:
  • Type 1:rare,avulsion fracture of the tip. stable and treatment is cervical collar.
  • type 2: fracture at the base of the odontoid.
    • ant .displ.(flex.inj.) is more common than post displ.(ext.inj.).
    • nonunion rate is 20-80% especially age >50 y.
  • Type 3:fracture through the body.
    • nondisplaced: cervical orthosis or halo.
    • displaced: halo jacked for 3m.
fixation of odontoid



fractures through pedicle of c2
Fractures through pedicle of C2:
  • Mechanism of Hangman fracture :ext.inj.
  • Types:
    • type 1: minimal displacement(less than 3mm)
    • type 2: significant displacement (>3mm) and angulation(>11 deg.)
    • type 2A: minimal displacement(<3mm) and angulation(>11 deg.)
    • type 3: associated facet dislocation.
fractures through pedicle of c21
Fractures through pedicle of C2:
  • Treatment:
    • type 1: halo jacket for 12 w.
    • type 2:traction for 2-3w for reduction +halo for 10-12w.
    • type 2A: no traction,extention,and compression,halo for 3m.
    • type 3 or late instability or nonunion: ant.C2-C3 fusion or post pedicular screw fixation(C2-C3 plating.
m r i of cervical

M.R.I of cervical

At C4-C5 , Disruption and Widening of the intervertebral Disc, compression fracture of C5, anterolisthesis of C4-C5

facet fracture dislocation
Facet fracture/dislocation:
stable lower cervical injuries
Stable Lower Cervical Injuries:
  • unilateral facet dislocation
  • compression fx.
  • hyperextension injuries
  • clay shoveler,s fx. (fx of s.p)
instability defined by
Instability defined by:
  • X -rays

* plain ,C.T.S , M.R.I

  • Clinical

* neurologic deficits

* persistant pain

white diagnostic checklist 5 is unstable
ant element=2

post element=2

sagital translation>3.5 mm or20% vertebra=2

sagital plan rotation > 11deg.=2

poitive stretch test=2

cord damage=2

root damage=1

abnormal disc narrowing =1

dangerous loading anticipated =1

White diagnostic checklist:>5 is unstable
management with spinal orthses
Management withspinal orthses
  • GOALS of immobilization by s.ort:
    • reduce motin in unstable segment.
    • reduce pain .
    • correct deformity.
    • protect the spinal cord.
four type of cervical orthoses
Four type of cervical orthoses:
  • Collars:
    • soft collar and philadelphia collar
  • Poster-type orthoses:
    • gliford and somi
  • Cervicothoracic devices:
    • minerva body jaket
  • Halo orthoses: halo vest
miami jackson collar for cervical stabilization
Miami-Jackson collar

For cervical stabilization

ant odontoid scrow fixation
Ant. Odontoid




Thoracic & Thoracolumbar

Spine Fx.

* Compression Fx.

* Burst Fx.

* Seat belt Fx.

* Fx. dislocation

seat belt type injuries

seat belt-type injuries

One level

Chance fx.

Through the bone

Two level

flexion rotation type inj

Flexion-rotation type inj.

Through the bone (slice fx.)

Through the disc

general symptoms signs1
General Symptoms & Signs :
  • Pain &Tenderness
  • Skin abrasions or contusions
  • Subcutaneous Hematoma
  • Muscle Spasm
  • Cripitation in Touch
  • SpinalDeformity
neurologic injury
Neurologic Injury:
  • 10% - 38% all TL Injuries
  • # 50% Fracture-Dislocations
  • Trauma between T5 - T9 has more chance for N.D.
neurological exam1
Neurological Exam:
  • Complete or Incomplete
    • Frankel Classification
    • ASIA Motor index Score
  • Repeated Examination
frankel classification
Frankel Classification
  • A :Complete loss(motor & sensory)
  • B : ,, motor loss,some sensory
  • C :Motor useless, Sensory good
  • D :Motor useful , but weak
  • E :Neurologically Intact
neurological exam2
Neurological Exam:
  • Dtection & Documentation :
    • Sensory Level
    • Posterior Column function
    • Sacral Sensory Sparing
    • Muscle Weakness (0 - 5 )
    • Pathological Reflex (BCR & Babinski)
    • Rectal Exam for Tone & cotracture
prognostic signs
Prognostic Signs:
  • Spinal shock
  • Bulbocavernosus & Anal Reflexes
  • Some return of Motor or Sensory function
clinical syndromes
Clinical Syndromes:
  • mixture of Cord & Root Syndromes. (T11 - L2 )complete sacral cord Damage & variable sparing of the lumbar roots.
  • (the most common syndrome)incomplete sacral cord lesions (less common)
clinical syndromes1
Clinical Syndromes:
  • solitary or multiple Radiculopathies
  • Cauda equina syndrome
  • X- Ray
    • 5%-20% F# are multiple
    • 5% at noncontaguious level
  • Lateral View
  • Oblique Views
  • A-P View
  • Flexion & Extension Views (CI)
  • A-P View of Pelvis
abnormalities in x ray
Abnormalities in X-Ray:
  • Abnormalities of Alignment
  • Kyphotic angulation
  • loos of lumbar lordosis
  • Vertebral disruption
abnormalities in x ray1
Abnormalities in X-Ray:
  • Disc space Narrowing
  • “Naked Facets”
  • interspinous distance Widening
  • Paraspinal soft tissue mass
  • Loss of the psoas stripe
  • CTScan
    • on areas suspected
    • bone & soft tissue windows
    • 4 - 5- mm -thick
    • Sagital re-formation
  • MRI
    • Adventages:
    • better visualization of the cord & Ligaments
    • Multiple plan of images
    • Disadventages:
    • restriction for life support Equipments
    • motion artifact
    • marginal bony detail
all organs will be involved
All Organs will be involved
  • 2 Main cause:1 - Immobility2- loss of central control ( paralysis )
  • Decubitus Ulcer
    • Sacrum
    • Occiput
    • Heel
    • Shoulder
    • Trochanter
skin ulcers
Skin Ulcers
  • Prevetion:
        • Roto-Rest table
        • Skin Hygiene
skin ulcers1
Skin Ulcers
  • Treatment:
  • Cost # $75000
  • Most common complications in quadriplegic Patients in ICU
  • Cause of Complications:
    • Paralysis of Muscle
    • Secretions Stasis
    • Atelectasis
    • Direct trauma to lung
respiratory complications
Respiratory Complications
  • Pneumonia
  • Pneumothorax
  • Plural efusion
  • Lung abscess
respiratory complications1
Respiratory Complications
  • Treatment:
    • Profilactic Intubation
      • nasotracheal Route
    • above C4: Elective Tracheostomy
    • Periodic monitoring Exam; X-Ray; Ultasound;
  • Arrhythmias
  • Phlebitis
  • Deep vein thrombous
  • Pulmonary emboli
        • Fatal Type : %3 - %13
  • Prevention:
    • Constant EKG monitoring
    • CVP & Swan-Ganz catheter
    • prophilactic Heparin
    • Compression leg devices
    • Kinetic therapy
urinary system
Urinary System
  • frequent Infectinos
  • Calculus Formation
  • Incotinance
  • Retention
urinary complications
Urinary Complications:
  • Prevention:
    • maintain good urinary output #400 ml/4h
    • Culture from Foley/ per 4 days
    • Intermittent Catheterization /per 4 h
  • Ileus
  • Acid hypersecretion
  • GI Ulcerations
  • GI Hemorrhage
  • chronic Constipation
  • Pancreatitis
  • Prevention:
    • H2 blocker or similar drugs
    • Gastric secretion drainage
    • central Hyperalimentation
    • start feeding after good bowel sound
skeletal system
Skeletal System
  • Massive “ Ca “ moblization:
    • urinary stones
    • heterotopic Bone
    • osteoporosis
    • high risk of Pathological fr#
psycological complications
Psycological complications:
  • Denial Phase
  • Anger phase
  • Depression phase
  • Coping Phase
miscellaneous complications
Miscellaneous complications:
  • Sepsis
    • Most common cause of Morbidity in Spinal injury
    • urinary or bed sore
  • Catabolic state
  • Neurogenic Hypotension