Spine Injuries

SPINE INJURIES

CERVICAL SPINE
Classification of Cervical Spine Injuries
Stable Injuries:
Hyperflexion with compression fracture < style="FONT-WEIGHT: bold">Common Presentations
Posterior neck pain on palpation of spinous processes
Limited range of movement associated with pain
Weakness, numbness, or paresthesia along affected nerve roots

X-rays
AP and lateral views of cervical spine.
Open mouth view if suspected upper cervical injury
Swimmer's view if unable to see C7/T1

Assessment Guidelines for detecting abnormalities
Atlanto-dens interval (ADI) should be 3mm
Depth of prevertebral soft tissue: 5mm at C3, 15mm at C6
Atlantoaxial offset >6.9mm indicates rupture of transverse ligament and C1/2 instability
Spinal stenosis
Vertebral alignment >3.5mm : unstable fracture
Compression fracture >25% : unstable fracture
Angulation of intervertebral space >11 degrees: unstable injury
Overriding of vertebra bodies: 25% indicates unifacetal dislocation, 50% indicates bifacetal dislocation

Classification of Spinal Cord Injury
Complete and incomplete cord syndromes
Anterior cord syndrome
Central cord syndrome
Posterior cord syndrome
Brown-Sequard syndrome

Common Findings on Physical Examination
Spinal shock:
Flaccidity, areflexia, loss of anal sphincter tone, fecal incontinence, priapism, loss of bulbocarvenosus reflex
Last from a few hours to weeks, segmental reflexes begin to return when spinal shock starts to resolve. At that point, flaccid paralysis changes to spastic paralysis

Neurogenic shock:
Hypotension, bradycardia, flushed, dry and warm periphery
Due to loss of sympathetic tone

Autonomic dysfunction:
Ileus, urinary retention, poikilothermia

Complete Cord Syndrome
Spinal shock mimics a complete cord lesion. Doctors have to wait until spinal shock resolves to make an accurate estimate of patient's prognosis. Complete lesion will lead to permanent paraplegia

Incomplete Cord Syndrome
Partial sensory or motor function are impaired bilaterally; patient can expect to regain some degree of function

Anterior Cord Syndrome
Due to compression of the anterior spinal artery, which results in anterior cord ischaemia or direct compression of the anterior cord
Complete motor paralysis and loss of temperature and pain perception distal to the lesion
Light touch, vibration, and proprioceptive input are preserved

Central Cord Syndrome
Damage to the corticospinal tract, usually associated with a hyperextension injury in patients with cervical spondylosis or congenital stenosis of the cervical spine
Weakness, greater in the upper extremities than the lower extremities, and more pronounced in the distal aspect of extremity

Brown-Sequard Syndrome
Injury to one side of the spinal cord, resulting in hemisection of the spinal cord, caused by penetrating trauma or fracture of the lateral mass of a cervical vertebra
Posterior columns and spinothalamic tracts on the ipsilateral side are injured
Paralysis, loss of sensory sensation and proprioception on ipsilateral side, with contralateral loss of pain and temperature

Management
Primary survey
: Airway with cervical control
: Breathing
: Circulation with haemorrhagic control
: Disability
: Exposure

Keep cervical hard collar; add sandbags on both sides of head for unstable injuries
Complete secondary survey
In cases of spinal cord injury, whether complete or incomplete, to start IV methyprednisolone first dose (30mg/kg BW over 15 minutes followed by 45 mins later by continuous infusion of 5.4mg/kj/hr for 23 hrs. Please check with Spinal Surgeon before commencing on this) at the A&E

Disposition
Admit to Department of Orthopaedic Surgery if isolated cervical spine/other orthopaedic injuries
Admit to Department of Surgery if associated with more life-threatening cardiothoracic, abdominal or unstable head injuries.