Spine anatomy * X-ray Spine anatomy * X-ray Cervical spine Cervical spine Thoracic spine Thoracic spine Lumbar spine Lumbar spine

Spine trauma Spine trauma Cervical spine Cervical spine Thoracic & lumbar spine Thoracic & lumbar spine

Trauma patient with spine lesion Trauma patient with spine lesion

Cervical spineCervical spine

Spine Spine AnatomyAnatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

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Anatomy

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Cervical spine X-rayCervical spine X-ray

C spine X-ray

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4

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Lateral view

C spine X-rayLateral view

C spine X-rayLateral view

C spine X-rayLateral view

C spine X-rayLateral view

C spine X-ray

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2

AP view

C spine X-rayAP view

C spine X-rayAP view

C spine X-rayOblique view

C spine X-rayOblique view

C spine X-rayOblique view

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C spine X-rayOMO view

C spine X-rayOMO view

Thoracic spine Thoracic spine

Spine Spine AnatomyAnatomy

Anatomy

Normal kyphosis 15° - 50°Normal kyphosis 15° - 50°

Anatomy

Anatomy

T spine X-rayT spine X-ray

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T spine X-rayAP view

T spine X-rayAP view

T spine X-raylateral view

T spine X-raylateral view

Lumbar spineLumbar spine

Spine Spine AnatomyAnatomy

Anatomy

Normal lordosis < 60°Normal lordosis < 60°slop of sacral base = 45° from slop of sacral base = 45° from

horizon horizon

L spine X-rayL spine X-ray

L spine X-rayAP view

L spine X-rayAP view

L spine X-ray

AP view

L spine X-rayAP view

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L spine X-rayLateral view

L spine X-rayLateral view

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L spine X-rayOblique view

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Scotty dog sign

Scotty dog

L spine X-rayOblique view

L spine X-rayOblique view

L spine X-rayOblique view

للعمود بسيطة صورة دراسة للعمود عند بسيطة صورة دراسة عندالفقريالفقري

التناظر التناظر فوق المتراكبة للفقرات التشريحية العناصر بين فوق التمادي المتراكبة للفقرات التشريحية العناصر بين التمادي

الوجيهات ) – – الشوكية النواتئ األجسام الوجيهات ) – – بعضها الشوكية النواتئ األجسام بعضهاالمفصلية .. ( المفصلية .. (

يلفت أن يجب التمادي بهذا انكسار أو انحناء أي يلفت وجود أن يجب التمادي بهذا انكسار أو انحناء أي وجود . أذية لوجود . االنتباه أذية لوجود االنتباه

متساوية الفقرات بين متساوية الفواصل الفقرات بين الفواصل كسر خط كسر وجود خط وجود

C spine trauma C spine trauma

Denis’ three column modelDenis’ three column model of the spine of the spine

The stabilityThe stability

Anterior column injury → stable Anterior column injury → stable Anterior & middle column injury→more Anterior & middle column injury→more

unstableunstable 3 column injury → unstable 3 column injury → unstable

C2 tear drop fracture

stable

Hangman fracture

Unstable

Wedge fracture

Unstable

Tear drop fracture

C5-C6 Bilateral facet dislocation

C4-C5 Bilateral facet dislocation

Unstable

Unlateral facet dislocation

Unstable

C5 C6 bilateral facet subluxation

Unstable

Atlantodental interval

Atlanto-axial instability

Unstable

Power ratio

Occipitoatlantal articulation

T+ L spine traumaT+ L spine trauma

90 % of spine fractures90 % of spine fractures

Effects on spine‘s functionsEffects on spine‘s functions

1.1. Stability Stability

2.2. Posture Posture

3.3. Neural protectionNeural protection

4.4. Neurological function Neurological function

Denis’ three column modelDenis’ three column model of the spine of the spine

More columns damage → more instabilityMore columns damage → more instability

1- Stability 1- Stability

2- Posture and deformity 2- Posture and deformity

Pain Pain Imbalance at the fracture Imbalance at the fracture

site site Compensatory curves Compensatory curves

2- Posture and deformity 2- Posture and deformity

3- Neural protection3- Neural protection

Spinal deformity Spinal deformity

↓↓

spinal canal stenosis spinal canal stenosis

↓↓

Varying degree of compressionVarying degree of compression

Neural structures Neural structures occupiesoccupies

50% spinal canal volume 50% spinal canal volume

4- neural function 4- neural function

Nerve lesion Nerve lesion Cord lesionCord lesion

Nerve lesionNerve lesion(Overstretched–crushed–severed) nerve (Overstretched–crushed–severed) nerve

structuresstructures

↓↓

Irreversible Irreversible

Chance for recovery : Chance for recovery : Partial lesion Partial lesion Release within 8 hours Release within 8 hours

Cord lesion Cord lesion

Drug may give a chance Drug may give a chance

MPS ( corticosteroid )MPS ( corticosteroid ) Reduce necrosis / oedema Reduce necrosis / oedema In the first 8 hours In the first 8 hours

Regimen :Regimen :

30 mg/kg/15 minutes 30 mg/kg/15 minutes After 45 minuteAfter 45 minute

5.4 mg/kg/hour for 23 hour5.4 mg/kg/hour for 23 hour

Lesion classificationLesion classification

T vertebra Burst fracture

L2 burst fracture

L3 burst fracture with rotation

T8 burst fracture + T9 wedge fracture

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8

Trauma patient with Trauma patient with spine lesionspine lesion

MVA45%

Falls20%

Sports15%

Acts of violace15%

other 5%

Causes of spinal column and spinal cord injury

Trauma patientTrauma patient The A – B – C – DThe A – B – C – D RESUSCITATION ( BP )RESUSCITATION ( BP ) Conscious level ( Glasgow coma scale ) Conscious level ( Glasgow coma scale ) Assessment of injuries Assessment of injuries ( Determine the ( Determine the

PRIORITY )PRIORITY )

Trauma patient - Trauma patient - accident accident scene scene

A : airways A : airways B : breathing B : breathing C : circulation & cervical spine C : circulation & cervical spine D : disability – drugs D : disability – drugs E : exposure ( undress the patient )E : exposure ( undress the patient )

Spinal column injury must be suspected in in all Spinal column injury must be suspected in in all poly-trauma patientspoly-trauma patients,,

especially < intoxicated – unconscious > especially < intoxicated – unconscious > individualsindividuals . .

Trauma patient - Transfer Trauma patient - Transfer

Scoop-style stretcher

Trauma Trauma patient patient Transfer Transfer

Trauma patient - Trauma patient - ResuscitationResuscitation

Blood pressureBlood pressure

BP > 85 mm Hg BP > 85 mm Hg → → better neurogenic better neurogenic outcomeoutcome

Neurogenic shock Neurogenic shock

3 vital signs indicates above T6 injury : 3 vital signs indicates above T6 injury : Hypotension Hypotension Hypothermia Hypothermia BradycardiaBradycardia

Disruption of sympathetic outflowT1-L2Disruption of sympathetic outflowT1-L2

↓↓

unopposed vagal toneunopposed vagal tone

Low blood pressure ..!?Low blood pressure ..!?

↓ ↓ BP + bradycardia =Neurogenic shock BP + bradycardia =Neurogenic shock

↓ ↓ BP + tachycardia = blood loss BP + tachycardia = blood loss occult intra-abdominal injuriesoccult intra-abdominal injuries

How to deal with Neurogenic shock : How to deal with Neurogenic shock : volume replacement volume replacement vasopressorsvasopressors

And of course<Treat other injuries> And of course<Treat other injuries>

Trauma patient - Trauma patient - ResuscitationResuscitation

Trauma patient - Trauma patient - AssessmentAssessment

Physical examination : Physical examination : Head Head

lacerations lacerations Contusions Contusions Facial fractures Facial fractures ear canal - nasal leakage ( CSF – blood ) ear canal - nasal leakage ( CSF – blood )

Spinous processes palpation Spinous processes palpation Bowel / bladder incontinence Bowel / bladder incontinence Penile erection Penile erection Occult injury ( abdomen – chest – Occult injury ( abdomen – chest –

extremities ) extremities )

Neurologic evaluation Neurologic evaluation

Level of conscious : Level of conscious : Glasgow coma scale Glasgow coma scale

Eyes open Eyes open Best verbal responseBest verbal response Best movement response Best movement response

Sensory examination Sensory examination

DermatomDermatomes es

the nipple line )T4(

xiphoid process )T7(

umbilicus )T10(

inguinal region )T12, L1(

The perineum and perianal region )S2, S3, S4(

the nipple line )T4(

xiphoid process )T7(

umbilicus )T10(

inguinal region )T12, L1(

The perineum and perianal region )S2, S3, S4(

Motor examination Motor examination

Motor examination Motor examination

Reflexes Reflexes Stretch reflexes: Stretch reflexes: Spinal shock = absent Spinal shock = absent Upper motor neuron lesion = Upper motor neuron lesion = hyperreflexia + spasticity hyperreflexia + spasticity

+ clonus + clonus Lower motor neuron lesion = absent Lower motor neuron lesion = absent

Reflexes Reflexes

Planter reflex : Planter reflex : Babinski’s sign Babinski’s sign Oppenheim’s sign Oppenheim’s sign

Cremasteric reflex T12-L1Cremasteric reflex T12-L1

Lesion level Lesion level

The most caudal segment with both The most caudal segment with both sensory and motor function bilaterally sensory and motor function bilaterally

Complete / incomplete cord Complete / incomplete cord lesion?lesion?

CompleteComplete : no motor/sensory : no motor/sensory function exist more than 3 segments function exist more than 3 segments below the site of injury.below the site of injury.

IncompleteIncomplete : some neurologic : some neurologic function below it .function below it .

Just to Just to remember !remember !

Classification Classification Central cord syn. Posterior cord

syn.

Anterior cord syn.

Brown-Sequal syn.

Sacral sparing Sacral sparing Continued function in the conus medularis =Continued function in the conus medularis =

incomplete cord injuryincomplete cord injury

Assessment :Assessment : Perianal sensation Perianal sensation Toe flexion Toe flexion Rectal sphincter Rectal sphincter

Spinal shockSpinal shock

After severe spinal cord injury After severe spinal cord injury A state of complete spinal A state of complete spinal AreflexiaAreflexia . . Last for varying length of time .Last for varying length of time .

99% within 24 hour.99% within 24 hour. Evaluation by : Evaluation by :

Testing the bulbocavernosus reflex ( S3 – Testing the bulbocavernosus reflex ( S3 – S4 )S4 )

Anal wink reflex Anal wink reflex

Bulbocavernosus reflex Anal wink

After injury : After injury : No evidence of spinal function below the No evidence of spinal function below the

level of injury ( even bulbocavernosus level of injury ( even bulbocavernosus reflex ) → reflex ) → no determination of completeness of injury no determination of completeness of injury

Return of bulbocavernosus reflex with Return of bulbocavernosus reflex with no sacral sparing signs → complete no sacral sparing signs → complete lesion lesion

Spinal shockSpinal shock

Roentgenogram Roentgenogram

Plain Xray : Plain Xray : Routinely Routinely Chest Chest Pelvis Pelvis Cervical spine <AP/Lateral>Cervical spine <AP/Lateral>Poly trauma Poly trauma <AP/Lateral> thoraco-lumbar spine film<AP/Lateral> thoraco-lumbar spine film

CTCT MRIMRI

High dose intravenous methylprednisoloneHigh dose intravenous methylprednisoloneWithin 8 hours = more significant improvement Within 8 hours = more significant improvement

30mg/kg in 15 minutes → after 45 minutes →30mg/kg in 15 minutes → after 45 minutes → 5.4mg/kg/hr in the remained 23 hour 5.4mg/kg/hr in the remained 23 hour

Complications : Complications : Wound infectionWound infectionGI Haemorrhage GI Haemorrhage

ER intervention ER intervention

Osmotic diuretics Osmotic diuretics Manitol Manitol Low molecular weight dextran Low molecular weight dextran

Used in head trauma Used in head trauma

No clinical effectiveness in spinal cord No clinical effectiveness in spinal cord injuryinjury

ER intervention ER intervention

Cervical stabilization :Cervical stabilization : Bilateral sand bag + taping Bilateral sand bag + taping Philadelphia collar Philadelphia collar Traction :Traction :

Gardner wellsGardner wells Halo vestHalo vest

ER intervention ER intervention

Taping

Philadelphia collar Philadelphia collar

Gardner-wells tongs Gardner-wells tongs

Halo vest orthosisHalo vest orthosis

Thoraco-lumbar bracesThoraco-lumbar braces

Jewett brace Jewett brace Custom-molded TLSOCustom-molded TLSO

Jewett brace Jewett brace

Full contact braces Full contact braces

MoKazem.com

من • تقديمها و إعدادها تم محاضرات سلسلة من هي المحاضرة هذه , دمشق مشفى في العظمية الجراحة شعبة في المقيمين األطباء قبل

. . ميرعلي بشار د إشراف تحت• . المحاضرة هذه في الواردة األخطاء عن مسؤول غير الموقع

•This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali.

•This site is not responsible of any mistake may exist in this lecture.

كاظم. مؤيد Dr. Muayad Kadhimد