Spine Fractures

Cervical Spine Fractures

Anatomy

spinal cord occupies ~ 35% of canal at the level of the Atlas and ~ 50% of the canal in the lower cervical region (C2-7) and the thoracolumbar spine

History

nature of incident
any neurological symptoms, any change in neurol status
LOC
head/ pectoral girdle injury

Examination


observe

head control
head injuries, pectoral girdle injuries: contusion
voluntary movement of all 4 limbs
Priapism
any limitation of movement of the pts head to either side

Palpate

tenderness over head + back off neck
step in spines
local haematoma

Neurological exam


Sensory

C2
back of head
C3
front of neck
C4
lat and inf over clavicles down to 2nd interspace
C5 - T1
upper limb
T2
below nipple
T10
unbilicus
L1
groin
L2- S2
lower limb
S3- S5 + coccygeal roots
perianal/ saddle


-once the sensory level is determined, examine distally for any evidence of sparing.
Sacral sparing indicates preservation of the lateral columns and recovery of lost muscle function is quite likely

Motor

after the sensory exam the diagnosis of a root lesion or cord lesion can be made and the completeness determined
Examine sequential nerve roots

C4
pt breaths diapragmatically
C5/6
biceps
C5
deltoid
C6
ECRL/ECRB
C7/8
triceps
C7
EDC
C8
FDP/FDP
T1
intrinsics
L1/2
adductors
L3/4
knee extension
L5/1
knee flexion
L4
tib ant
L5
EHL/ peronei
S1/2
ankle plantar flexion


Rectal inability of the pt to feel the finger in the rectum confirms a complete sensory lesion

If sphincter doesn't contract voluntarily about the finger + there are no other signs of voluntary motor power,complete motor paralysis is confirmed

Bulbocavernosus reflex: a squeeze on the glans, a tap on the mons or a tug on the catheter stimulating the trigone of the bladder causes reflex contraction of the anal sphincter about the gloved finger

If spinal shock is present a complete lesion cannot be diagnosed with certainty- if the bulbocavernosus has not returned in 24 hrs its absence is due to complete lesion as spinal shock resolves within 24 hrs

Spinal Cord Lesions

Spinal Shock

Wrt spinal cord injury = a spinal cord nervous tissue dysfunction based on physiologic dysfunction rather than structural disruption.
Spinal shock has resolved when the reflex arcs below the level of the injury begin to function again

Root injuries

are essentially peripheral nerve injuries , partial recovery is expected
root avulsion is rare except in plexus injury

Incomplete spinal cord lesions

any sparing distal to the injury = incomplete lesion= possible recovery
the greater the sparing the greater the prognosis

Brown- Sequard

an injury to either side of the cord (hemisection)
ipsilateral: muscle paralysis and jt position/ vibration loss
contralateral: pain and temperature loss
- good prognosis, 90% regain bladder / bowel function + walk

Central cord syndrome

most common incomplete cord injury, assoc with extension injury to Cx spine in middle aged pt

Impact direct to the central grey matter®severe flaccid LMN paralysis of the upper limbs

Damage to the central portion of the corticospinal and spinothalamic long tracts in the white matter®UMN spastic paralysis of the lower limbs and trunk
The sacral tracts are peripheral and are usually spared and the pt has sacral sparing

Prognosis
50-60% have progressive return of motor and sensory function to lower limbs- but poor recovery of hand function due to irreversible damage to the central grey matter

Anterior cord syndrome

complete motor and sensory loss apart from dorsal column sparing with deep pressure/ proprioception/ vibration as only remaining modality

prognosis
good if recovery progressive within 24 hrs
after 24 hrs prognosis poor
10-15% have recovery

Posterior cord syndrome

loss of deep pressure/ proprioception/ vibration only

Complete Cord Injuries

Frankel classification of Neurological Deficits in pts with Cord injuries

ref: Frankel etal "The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia: Part 1."
Paraplegia 7: 179-192, 1969
Types

absent motor and sensory function
sensation present, motor function absent
sensation present, motor function present but not useful (gd 2-3/5)
sensation present motor function active and useful ( gd 4-5/5)
normal motor and sensory function

Assessment of Cx cord injuries

Plain XR

direct XR evidence of instability

Increased angulation bw spinous processes more than 11 deg than in adjacent segments
Ant or post translation of the vertebral bodies more than 3.5 mm
segmental disc space widening on lat XR
facet jt widening
malalignment of spinous processes of ant view
Rotation of the facets on lat XR
at tilt of vertebral body on ant XR

XR findings suggestive of unstable injuries

Increased retro pharyngeal space - ant to C3 normal not more than 3 mm
C4 + below- normal varies 8-10 mm
minimal compression fracture of ant vertebral bodies
Avulsion fracture at or near insertion of spinal ligs
nondisplaced fracture lines

Tomography

good for posterior elements, dens fracture

CT

assess bony encroachment on canal , best method for accurate bone definition

MRI

evaluate neural elements
disc disruption
ligamentous disruption

Stress XR's

flexion/ extension contraindicated in altered state of consciousness