Management of Spinal Injuries
- Three
Column Theory Disruption of at least 2 columns is necessary for instability
- Anterior
column: Anterior longitudinal ligament, anterior annulus fibrosus,
anterior 2/3 vertebral body
- Middle column:
Posterior longitudinal ligament, posterior annulus fibrosus, posterior
1/3 vertebral body
- Posterior
column: posterior bony complex, posterior ligamentous complex
(supraspinous, intraspinous, capsule, and ligamentum flavum)
- Anterior
Cord Syndrome flexion injury
- Loss of
sensation and pain (anterior and lateral spinothalamic) with spastic
paralysis (corticospinal)
- Central
Cord Syndrome extension injury in previously stenotic spine
- Loss of
sensation/joint position (posterior columns), loss of sensation in arms
and shoulders, weakness of upper extremities (medial corticospinal tract)
- Cervical
Fractures
- Atlanto-occipital
dislocations
- longitudinal
(pure axial), anterior, or posterior
- distance
between dens and basion greater than 12.5 mm
- more
common in children
- Powers
ratio = BP/OA (basion (front of foramen magnum) to posterior arch of
atlas divided by opisthion (back of foramen magnum) to anterior arch of
atlas) normally < 0.9; if >1, significant risk of AOD
- Atlanto-axial
dislocations
- Rotatory
- C1 rotates
on C2 with locked facet; associated with flexion injury; more common
with rheumatoid arthritis or pharyngitis
- more
common in children
- "cock-robin"
head position
- reduce
and fuse
- Anterior
- 1/3
die or have serious neurological deficit
- if
transverse anterior ligament (TAL) intact, can try halo before fusion
- C1
fractures (Jefferson Fractures)
- bilateral
burst fracture of C1 anterior and posterior neural arch; stable unless
transverse ligament disrupted
- usually
from axial loading
- neurological
deficits are rare
- 40%
have associates C2 fracture
- Rule
of Spence
7 mm overlap of both C1 lateral masses on C2; indicates disruption of
transverse ligament, need for halo fixation
- Unstable;
treat with halo vest
- if C2
feacture is present, treatment is usually based on the C2 fracture
- C2
fractures
- Hangman's
fracture
- C2
traumatic spondylolisthesis with bilateral pedicle fracture, displacing
body forward
- bilateral
fracture of pars interarticularis (thus traumatic spondylolisthesis)
- usually
due to hyperextension and axial loading (often diving injury)
- often
has C2 on C3 anterolisthesis
- neurological
deficits are rare
- Type
I <3mm
subluxation, usually stable
- Type
II
>4mm subluxation or >11 degrees of angulation; less stable
- Type
III
hangman's fracture with facet disruption; can be fatal, do not
reduce with traction
- Unstable,
but >90% heal with halo bracing
- C2-3
ACDF can be used for treatment failures of fractures with disc
herniation
- Odontoid
fractures
- Neurological
deficits are rare
- Classic
pose holding head in hands when going from sitting to supine (to
prevent pain)
- Type
1 tip
of dens; avulsion of the alar ligament; stable, but heal poorly and
hardest to fix
- Type
2
fracture through the neck/body of the dens
- most
unstable; 30% nonunion rate (70% if greater than 6 mm; 10% if less than
6 mm)
- from
flexion/extension injury
- treat
with halo or ORIF
- direct
screw fixation is best but must be sure TAL is intact; fracture line
should not be parallel to screw trajectory
- Type
3 extension
into C2 vertebral body; unstable, but 90% heal with halo vest
- Compressive
subaxial cervical fractures
- Clay
shoveler's
- stable
isolated C7 spinous process avulsion
- common
with hyperextension of arms over head, often to stop a fall
- Simple
avulsion fracture of a posterior spinous process
- Stable
- Compression
fracture
- from
pure axial load
- treat
with collar
- Burst
Fracture
- from
pure axial loading or flexion/compression
- almost
always unstable
- Teardrop
fracture
- not to
be confused with osteophyte fracture or avulsion
- hyperflexion
injury
- usually
associated with retrolisthesis of fractured vertebrae
- high
rate of soft tissue disruption
- Distractive
subaxial cervical fractures
- Unilateral
perched/locked facet
- produces
rotatory subluxation
- only
25% neurologically intact
- oblique
xray shows "bow-tie" sign from disarticulated facet
- CT
shows empty facet
- reduced
state more stable than perched/locked (1 normal facet)
- Bilateral
perched/locked facets
- high
rate of cord injury
- direct
(non-rotatory) anterolisthesis
- reduced
state less stable than perched/locked
- Treatment
may attempt closed reduction starting with 3 lbs per level (do not
exceed 10 lbs per level)
- Thoracolumbar
Fractures
- Three
column model (Denis) anterior 2/3 of body, posterior 1/3, posterior
elements
- Compression
fractures
- Anterior
column only
- From
flexion/compression or true axial load
- Wedging
of anterior portion of vertebral body with preservation of posterior
vertebral body height
- Common
fracture in older osteoporotic patients
- Stable
- Burst
fractures
- anterior
and middle columns
- From
axial loading or high-force flexion/compression
- Comminuted
fracture involving entire vertebral body
- Often
propels fragments into spinal canal
- Caused
by vertebral compression
- Unstable
- T-L
junction most common
- Flexion-Distraction
Fracture
- seat-belt
injury, Chance fracture
- fulcrum
around instantaneous axis of rotation; posterior elements ripped apart
while anterior column compressed
- Can be
ligamentous type or bony type
- Tearing
of posterior ligaments with widening of posterior elements and fracture
into posterior aspect of vertebral body
- Caused
by distraction applied to spine in flexion
- Unstable
- Fracture
Dislocation
- Complex
mechanisms involving shear and/or rotational forces
- Sacral
Fractures
Denis Classification
- Type
I through
ala, lateral for foraminae; low rate of neurological deficit
- Type
II
through foraminae; high rate of unilateral radiculopathy
- Type
III
through central canal; high rate of cauda equine
- "SCIWORA"
(Spinal Cord Injury without Radiographic Abnormality)
- Seen
mainly in pediatric patients
- Transient
or prolonged neurologic deficit in patient that a fracture or subluxation
cannot be documented
- Probably
secondary to cord contusion
- Obtain:
- MRI to
R/O cord injury
- Plain spine
films to R/O congenital cervical stenosis
- Treatment:
- Immobilization
in Philadelphia collar, 2 poster brace, or Minerva jacket usually for 6
wks
- Advise
patients that contact sports carry risk of repeat spinal injury
BASIC MODES OF FAILURE IN MAJOR TYPES OF
SPINAL INJURY
Type of Fracture
|
Anterior
|
Column Involved
|
Posterior
|
Compression
fracture
|
Compression
|
None
|
None
(severe-distraction)
|
Burst
fracture
|
Compression
|
Compression
|
None
|
Seat belt
type fracture
|
None or compression
|
Distraction
|
Distraction
|
Fracture
dislocation
|
Compression
Rotation
shear
|
Distraction
Rotation
shear
|
Distraction
Rotation
shear
|