Historical perspective



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Chapter 33 Spinal injuries

鍾耀文 / 李芳年, 2000年12月27日


Historical perspective


¤ Hunched vs upright posture.

¤ 1 gm weight dropped from a height of only 10 cm on to a monkey’s surgically exposed spinal cord result in permanent neurologic dysfunction.


Epidemiology


¤ Automobile and motorcycle accidents : 1/2 spinal injuries

¤ Falls 20%, sporting activities 15%,

intentional acts of human violence 15%

¤ Arthritic disease, malignancy, osteoporosis in the elderly

¤ Median age 25 y/o, men to women: 4 to 1

Pathophysiology


¤ Spinal column injury

Normal anatomy:

33 bony vertebrae: 7C 12T 5L 5S(1) 4C(1) Fig 33-1 p463

2 columns Fig 33-2 p465

Riggins and Kraus vertebral injuries :14% spinal cord injuries

Various types of vertebral injuries Table 33-1 p466

Hardy’s report: 141 to 384 ( 37 % ), evidence of neurologic deficit

No radiographically demonstrable vertebral injuries

¤ Classification of spinal injuries : Table 33-2 p466


  1. Flexion

Simple wedge fracture: stable, rarely NS damage Fig 33-3 p 467

Teardrop fracture: ligamentous injuries, may NS Fig 33-4 p467

Clay shoveler’s fracture: oblique fracture of the base of the spinous process of one of the lower cervical segments, Fig 33-5 p468 ( avulsion fracture ), direct trauma-pool cues, baseball bats,

Sudden deceleration, Stable, no NS



Subluxation: ligamentous complexes rupture without bony injuries, widening of the interspinous space and gaping of the intervertebral space posteriorly, potentially unstable, rarely NS

Fig 33-6 p469



Bilateral facet dislocation: high incidence of spinal cord injury,

extremely unstable condition, soft tissue disruption, the displacement is greater than 1/2 AP diameter of the lower vertebral body, Fig 33-7 p470



Atlantooccipital or atlantoaxial joint dislocation:

With or without an associate fracture of the odontoid

Unstable( lack of muscle and ligamentous support )

Fig 33-8 p470



Lateral displacement of the odontoid: unstable Fig33-9

Fracture through the transverse process: stable p471

  1. Flexion-rotation

Unilateral facet dislocation: fulcrum, contralateral dislocate

rest within the intervertebral foramen, locked in place-stable

less than 1/2 AP diameter, Fig33-10 p472, oblique projections

bow tie deformity



C1-C2 level---Rotary atlantoaxial dislocation: unstable

asymmetry between odontoid process and lateral masses of C1 Fig 33-11 p474



Thoracolumbar and lumbar region: unstable, Fig 33-12 p474

  1. Extension

Posterior neural arch fracture of the atlas: compression posterior elements- occiput and the heavy spinous process of the axis, Fig 33-13 p475, potentially unstable

Hangman fracture or traumatic spondylolysis of C2:

cervicocranium, bilateral fractures of the pedicles of the axis occur with or without dislocation, Fig 33-14 p476, unstable, cord damage minimal, neural canal is greatest at the C2, death from hanging commonly resulted from strangulation rather than cord damage.



Extension teardrop fracture: Axis, triangular-shaped fracture, Fig 33-15 p476, C5 and C7—diving accidents—central cord syndrome-ligamentum flavum buckles into.

  1. Vertical compression

Burst fracture, Fig 33-16 p477, stable, impinge on or penetrate the ventral surface of the spinal Cord

The Jefferson fracture of C1: occipital condyles to atlas

Fracture of the Ant. and Post. arches of the atlas and a disruption of the transverse ligment, widening of the predental space( adults 3 mm, children 5mm), prevertebral hemorrhage, Fig 33-17 p478

Extremely unstable

Isolated fracture of the articular pillar or the vertebral body:

Fig 33-18 p479

¤ Spinal cord injury

Primary spinal cord injury

Penetrating trauma or massive blunt trauma

Elderly patients with cervical osteoarthritis and spondylosis, Fig 33-19 p479

Primary vascular damage to the spinal cord: extradural hematoma

Bleeding disorders, undergoing anticoagulation therapy

Felty’s syndrome, Epidural hematoma-blunt trauma

Fig 33-20 p480

Secondary spinal cord injury

A complex cascade of events, free radical-induced lipid peroxidation reactions, progressive ischemia of gray and white matter


Diagnostic findings


Clinical features

Neurologic evaluation



Observation: inspection, head or facial trauma-4% to 20% spinal cord injuries, breathing pattern-phrenic nerve , diaphragm ,C3 and C4 level, abdominal breathing-lower cervical injury, Horner’s syndrome-unilateral facial ptosis, miosis, anhydrosis-C7 to T2 cervical sympathetic chain

Speak with the patient-history, severe pain in the sensory dermatome corresponding to the level of the spinal injury(C2 occipital pain, C5 trapezius muscle ), burning-hand syndrome C6 to C7 extension injuries

Palpation: tenderness, deformity, muscle spasms

Motor activity: table 33-3, repeated at frequent intervals-cephalad progression

Deep tendon reflexes: Table 33-4,

upper motor neuron(spinal cord)-paralyzed muscles, intact deep tendon reflex, lower- absent DTR(nerve root or cauda equina)-surgically correctable lesion



Sensory function: Table 33-5, Fig 33-22, cotton wisp-light touch( posterior column function), pin-pain sensation( anterior spinothalamic tract function )
Complete spinal cord lesions:

Total loss of motor power and sensation distal to the site of a spinal cord injury. Longer than 24 hours-99% will not have functional recovery

Sacral sparing-perianal sensation, rectal sphincter tone, slight flexor toe movement.---partial lesion

Spinal shock: concussive injury, last less than 24 hours bulbocavernosus reflex-absent



Incomplete spinal cord lesions: Fig 33-23

Central cord syndrome

Degenerative arthritis of cervical vertebrae, greater neurologic deficit in the upper extremities, quadriplegic-sacral sparing, 50% a return of bowel and bladder control, ambulatory, regain some hand function



Brown-Séquard syndrome:

Hemisection of the spinal cord - penetrating lesion such as gunshot or knife wound, ipilateral motor paralysis and contralateral sensory hypesthesia distal to the level of injury---all retain control of bowel and bladder



Anterior cord syndrome:

Cervical flexion injury—paralysis and hypalgesia (preservation of position, touch, vibratory sensations ), acute surgical intervention

Three additional spinal cord syndromes:

Dejeune onion skin pattern of analgesia of the face

Horner syndrome

Posteroinferior cerebellar artery syndrome


Radiographic evaluation


Indications: impaired consciousness, complaints of neck or back pain, evidence of significant head or facial trauma, signs of focal neurologic deficit, unexplained hypotension, suggestive mechanism of injury associated with other painful injuries, minor mechanism ofinjury(osteoporosis, arthritis, metastatic disease

Standard trauma series:



AP, lateral, swimmer’s, oblique, open-mouth or closed-mouth odontoid views, Fig 33-25, Fig 33-26

Cross-table lateral view: ABCs: Alignment( Fig 33-27 p489 )- 2 mm( Fig 33-28 p489 )-Predental space( 3mm adult, 5mm child) , bony changes-bony density, cartilage-space assessment-oblique view in confirming real subluxation , soft tissues- C2 ( 7 mm ), C3( 5mm ), C6 retrotracheal space 22mm( adults ) 14mm ( children)

Odontoid view: Fig 33-26

Other view:

AP view : A bulging of the mediastinal stripe-subtle thoracic vertebral body fracture, infection or neoplasm( Fig 33-30 p491)

Oblique view: posterior laminar fracture, unilateral facet dislocation, real subluxation( Fig 33-32 p492)-----laminae( shingles on a roof, intact ellipse ), Fig 33-31 p491

Lateral flexion and extension: slowly and gently flex and extend their neck for the x-ray examination but not to the point of causing pain or neurologic symptoms, 10 to 15 degrees

Further evaluation:

CT scan, Fig 33-33 p493

Major indication for CT scan in cervical spine trauma



  1. Inadequate plain film survey

  2. Suspicious plain film findings

  3. Fracture/displacement demonstrated by standard radiography

  4. High clinical suspicion of injury, despite normal plain film survey

Advantages :Fig 33-34 p494

  1. Improved fracture-detection rates

  2. Spinal canal evaluation, Fig 33-35 p494

  3. Paravertebral soft-tissue assessment

  4. Reduced manipulation of the patients and exposure to radiation

Disadvatages:

  1. Limited demonstration of vertebral body displacement or subluxation in the sagittal plane

  2. Poor visualization of horizontally oriented fractures

--------Spiral CT scan, Fig 33-36 p495( Volume scan )

Three-dimensional format, Fig 33-37 p495

C-spine injuries not apparent on plain film and axial CT

Fig 33-38 p 496

MRI scan: definition of the spinal canal, multiplanar capabilities, lack of ionizing radiation, surpassing myelography and postmelography CT scan, Fig 33-39 p497

Including acute disk herniation, ligamentous injuries, epidural and subdural hemorrhage, and vertebral artery occlusion

---potentially correctable surgically, Fig 33-40 p 498

---Cord edema or contusion vs Cord hemorrhage, Fig33-41 p499



Contraindications: the presence of a pacemaker, cerebral aneurysm clips, metallic ( ferromagnetic ) foreign bodies

Ligamentous injury, Fig 33-42 p500

Subarachnoid changes, Fig 33-43 p501

Management of spinal injuries


Spinal column stabilization

Prehospital care: 10% permanent impaired—immobilize the traumatized spine or sedate the patient---neck collar,sand bags, tape

Airway management—lesion above the level of C3

---careful orotracheal intubation with in-line spinal immobilization

Spinal shock: loss of neurologic function and accompanying autonomic tone below the level of a spinal cord lesion

---Flaccid paralysis with loss of all modes of sensory input, deep tendon reflexes, and urinary bladder tone, along with bradycardia, hypotension, hypothermia, and intestinal ileus.

---generally lasts less than 24 hours( days, weeks )

Pharmacologics for incomplete cord injury

Glucocorticoids, naloxone, thyrotropin-releasing hormone, dimethyl sulfoxide,calcium channel blockers, tirilazad meyslate, GM1 ganglioside, hyperbaric oxygen therapy



--------Methylprednisolone ( within 8 hours of injury )

30 mg/kg IV bolus, 5.4 mg/kg/hr for 23hr





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