Spine structured oral questions7: Spinal trauma
Spine structured oral questions7: Spinal trauma
EXAMINER: A 26-year-old man crashes his motor-bike and sustains the fracture shown. How would you go about assessing a patient with a suspected spinal injury? (Figure 5.9.)
CANDIDATE: The assessment of seriously injured patients begins with the Airway (with cervical spine control), Breathing and Circulation. Circulation assessment includes assessment for neurogenic shock. Then comes neurological disability assessment using the Glasgow Coma Scale followed by a log roll (looking for steps, swelling or bruising indicating posterior injury), rectal examination and neurological examination (using an ASIA chart). Initial imaging will include the trauma series (chest, c-spine and pelvis) X-rays. If a fracture is identified, imaging of the whole spine is required as there is a significant chance of a second fracture (10%). Once a fracture has been identified further imaging with a CT scan is indicated. MRI may also be required to assess disc and spinal cord injuries. Spine fractures are often associated with other injuries. Cervical spine fractures may be associated with vascular injuries, thoracolumbar fractures with visceral injuries and lumbar fractures with lower limb (calcaneal) fractures.
EXAMINER: What is neurogenic shock?
CANDIDATE: Neurogenic shock should be distinguished from hypovolaemic shock. Relative bradycardia and warm peripheries indicate the cause of shock is loss of sympathetic tone secondary to spinal cord injury ( SCI ).
Spinal shock is transient neurological dysfunction that is caused by a contusion or oedema of the spinal cord that usually resolves over 24–72 hours. The bulbocavernosus reflex (usually tested by pulling on an indwelling catheter) is the first reflex to return.
EXAMINER: Would you give this person steroids?
CANDIDATE: No. The current (2006) BOA guidelines on the initial care of patients with spinal cord injuries states ‘the use of high dose steroid in the management of acute spinal cord injury could not be recommended or supported on the current evidence’.1
EXAMINER: How do you classify thoracolumbar fractures?
CANDIDATE: I would use the AO classification. This divides thoracolumbar fractures into three types: A, B and C based on the mechanism of injury. Type A fractures are compression type injuries and are subdivided into three subtypes (type 1 – wedge, type 2 – pincer and type 3 – burst fractures). Type B fractures are distraction injuries associated with a fracture or ligamentous injury to the posterior column (flexion– distraction or hyper-extension injuries). They are subdivided into three types: type 1 – posterior ligamentous injury with anterior injury, type 2 (chance type) fractures of both anterior and posterior elements with distraction posteriorly, type 3 are associated with anterior distraction. Type C injuries are injuries that occur with rotation. The subtype C1 are A type fractures with rotation, C2 are B type fractures with rotation and C3 injuries are injuries with rotation and shear. Fractures become more unstable as type progresses from A to C and subtype from 1 to 3.
EXAMINER : What role does spinal surgery have and what factors do you know that indicate prognosis?
CANDIDATE: Incomplete spinal cord injuries are more likely to recover than complete injuries. Sacral sparing implies an incomplete lesion and improved prognosis. Spinal surgery attempts to decompress the injured spinal segment and stabilize the injury. Decompression aims to remove compression (either direct or indirect) but currently there is limited evidence showing improved neurological outcome. Stabilization of the spine reduces pain, facilitates patient handling and allows earlier mobilization helping prevent the complications associated with recumbency. Surgical stabilization prevents further displacement in unstable fractures preventing further injury and late deformity with better posture and balance. (A stable fracture is one that will not displace under normal physiological loads.)
1. The Initial Care and Transfer of Patients with Spinal Cord Injuries. London: British Orthopaedic Association, 2006.
Spinal trauma background knowledge
Vaccaro and colleagues have devised the TLICS system (thoracolumbar injury classification and severity score) for decision making in spinal trauma,1 based on the configuration of the fracture, neurological state of the patient and the integrity of the posterior ligamentous complex. Compression fractures score 1 , burst fractures 2, translational/rotation injuries 3 and distraction injuries 4. Patients that are neurologically intact score 0, nerve root or complete spinal cord injuries 2 and incomplete injuries 3. The posterior ligamentous component scores 0 if the ligament is intact, 2 if it is suspected and 3 if it is confirmed.
Patients with a score of < 3 are considered not to be operative candidates, and those with scores > 5 are considered for surgery.
1. Lee JY, Vaccaro A, Lim MR et al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci 2005;10(6):671–675.
Neurological injury
Neurological injury can be classified as ‘complete’ or ‘incomplete’. Incomplete injuries have a better potential for recovery. Various patterns of incomplete injury have been described:
Anterior cord syndrome – Loss of motor function with sparing of proprioception and pressure sensation (poor prognosis).
Posterior cord syndrome – Rare, there is loss of proprioception and pressure sensation but no motor loss (prognosis for recovery is relatively good).
Central cord syndrome – This is the most common with mixed motor and sensory loss typically greater in upper than lower limbs (prognosis for recovery is fair).
Brown–Sequard (hemicord) syndrome – Ipsilateral motor function and contralateral pain and temperature sensation. Commonly caused by penetrating injury and carries the best prognosis.
Complete injuries have no function below a certain level. The ‘level’ of the injury is determined by distal-most level with intact motor and sensory function (power 3/5, sensation 2/2 – intact light touch). Frankel grading system:
-
– Complete paralysis.
-
– Sensory preservation below level of injury – no voluntary motor function.
-
– Sensory preservation below level of injury – useless motor function.
-
– Sensory preservation below level of injury – useful voluntary motor function.
-
– Normal function.
Specific fractures
Occipital condyle fractures: Rare, mostly detected on CT, associated with cranial nerve dysfunction. Classified by Anderson and Montesano ( Type I comminuted axial impact fracture, Type II continuous with base of skull fracture, Type III avulsion at the attachment of the alar ligament). Treatment for types I and II is a cervical collar. Type III treated with halo vest or with occipitocervical fusion.
Atlanto-occipital joint subluxation: Rare,
Powers’ ratio defines subluxation (> 1 anterior subluxation < 1 posterior). Treatment is with halo-vest.
C1 (Atlas) fractures: Commonly associated with other injuries. Widening of lateral masses on ‘openmouth’ view or CT. Classified by Levine and Edwards into Type I posterior arch fractures, Type II lateral mass fractures and Type III burst fractures ( also known as Jefferson fractures). Treatment is with halo-vest immobilization.
C2 (Axis) fractures: two main groups
Anterior odontoid peg (Dens) fractures have been classified by Anderson and D’Alonzo into three types that guide treatment.
-
Fracture of the tip – treat symptomatically.
-
Fracture of the base of the odontoid. High rate of non-union. Treatment is either posterior stabilization or odontoid screw fixation. (Consider halo-vest immobilization if minimally displaced.)
-
Fracture through vertebral body. Management is usually with a halo vest.
The second group of C2 fractures are the pars (Hangman’s) fractures that represent a traumatic spondylolisthesis. Some are associated with facet joint dislocations which require reduction (open or closed), otherwise treat in halo vest.
C3 to C7 (subaxial) fractures
These comprise 80% of cervical spine fractures. Treatment of these injuries is guided by the Allen and Fergusson classification and is based on the mechanism of injury.
Vertical (axial) compression injuries
Stage 1 – Compression only – treat with a cervical collar.
Stage 2 – Compression and fracture with minimal displacement – treat with cervical collar or halo vest. Stage 3 – Fracture with displacement or fragmentation – may require surgery
Flexion–compression injuries
Stage 1 – Blunting of superior endplate – treat in cervical collar.
Stage 2 – Vertebral body beaking – treat in cervical collar.
Stage 3 – Beak fracture – consider surgery.
Stage 4 – Retrolisthesis < 3 mm – consider surgery.
Stage 5 – Retrolisthesis > 3 mm – consider surgery.
Flexion–distraction injuries
This mechanism frequently causes facet joint dislocations as a result of failure of the posterior tension band. Diagnosed on oblique radiographs. Treat with reduction (skull traction up to one-third body weight) and subsequent fusion.
Note: With reduction there is a risk of further injury that can be caused by an associated disc injury anteriorly. An MRI scan prior to reduction is required.
Extension–compression injuries
These injuries cause failure of the posterior elements in compression. Minor (minimally displaced) injuries can be treated in a cervical collar; posterior fusion surgery is considered for more severely displaced or comminuted fractures.
Extension–distraction injuries
The anterior column fails under distraction with anterior longitudinal ligament injuries associated with a vertebral body fracture. Displaced fractures require surgical stabilization. Minimally displaced injuries may be treated in a halo vest.
Lateral flexion injuries
Lateral flexion injuries typically either cause a unilateral compression fracture or a unilateral compression fracture with a distraction injury on the contralateral side. Displaced fractures associated with a contralateral injury require surgical stabilization. Minimally displaced injuries may be treated in a halo vest.
Sacral fractures
Denis Classification:
Zone 1 injuries lateral to the sacral foramina (L5 may be injured).
Zone 2 injuries through the sacral foramina (15 % have sacral root injuries).
Zone 3 injuries medial to the foramen (30–50 % have sacral root injuries).
Surgical treatment is indicated for fractures with neurological injury of displaced fractures
Spine structured oral questions7: Spinal trauma
EXAMINER: A 26-year-old man crashes his motor-bike and sustains the fracture shown. How would you go about assessing a patient with a suspected spinal injury? (Figure 5.9.)
CANDIDATE: The assessment of seriously injured patients begins with the Airway (with cervical spine control), Breathing and Circulation. Circulation assessment includes assessment for neurogenic shock. Then comes neurological disability assessment using the Glasgow Coma Scale followed by a log roll (looking for steps, swelling or bruising indicating posterior injury), rectal examination and neurological examination (using an ASIA chart). Initial imaging will include the trauma series (chest, c-spine and pelvis) X-rays. If a fracture is identified, imaging of the whole spine is required as there is a significant chance of a second fracture (10%). Once a fracture has been identified further imaging with a CT scan is indicated. MRI may also be required to assess disc and spinal cord injuries. Spine fractures are often associated with other injuries. Cervical spine fractures may be associated with vascular injuries, thoracolumbar fractures with visceral injuries and lumbar fractures with lower limb (calcaneal) fractures.
EXAMINER: What is neurogenic shock?
CANDIDATE: Neurogenic shock should be distinguished from hypovolaemic shock. Relative bradycardia and warm peripheries indicate the cause of shock is loss of sympathetic tone secondary to spinal cord injury ( SCI ).
Spinal shock is transient neurological dysfunction that is caused by a contusion or oedema of the spinal cord that usually resolves over 24–72 hours. The bulbocavernosus reflex (usually tested by pulling on an indwelling catheter) is the first reflex to return.
EXAMINER: Would you give this person steroids?
CANDIDATE: No. The current (2006) BOA guidelines on the initial care of patients with spinal cord injuries states ‘the use of high dose steroid in the management of acute spinal cord injury could not be recommended or supported on the current evidence’.1
EXAMINER: How do you classify thoracolumbar fractures?
CANDIDATE: I would use the AO classification. This divides thoracolumbar fractures into three types: A, B and C based on the mechanism of injury. Type A fractures are compression type injuries and are subdivided into three subtypes (type 1 – wedge, type 2 – pincer and type 3 – burst fractures). Type B fractures are distraction injuries associated with a fracture or ligamentous injury to the posterior column (flexion– distraction or hyper-extension injuries). They are subdivided into three types: type 1 – posterior ligamentous injury with anterior injury, type 2 (chance type) fractures of both anterior and posterior elements with distraction posteriorly, type 3 are associated with anterior distraction. Type C injuries are injuries that occur with rotation. The subtype C1 are A type fractures with rotation, C2 are B type fractures with rotation and C3 injuries are injuries with rotation and shear. Fractures become more unstable as type progresses from A to C and subtype from 1 to 3.
EXAMINER : What role does spinal surgery have and what factors do you know that indicate prognosis?
CANDIDATE: Incomplete spinal cord injuries are more likely to recover than complete injuries. Sacral sparing implies an incomplete lesion and improved prognosis. Spinal surgery attempts to decompress the injured spinal segment and stabilize the injury. Decompression aims to remove compression (either direct or indirect) but currently there is limited evidence showing improved neurological outcome. Stabilization of the spine reduces pain, facilitates patient handling and allows earlier mobilization helping prevent the complications associated with recumbency. Surgical stabilization prevents further displacement in unstable fractures preventing further injury and late deformity with better posture and balance. (A stable fracture is one that will not displace under normal physiological loads.)
1. The Initial Care and Transfer of Patients with Spinal Cord Injuries. London: British Orthopaedic Association, 2006.
Spinal trauma background knowledge
Vaccaro and colleagues have devised the TLICS system (thoracolumbar injury classification and severity score) for decision making in spinal trauma,1 based on the configuration of the fracture, neurological state of the patient and the integrity of the posterior ligamentous complex. Compression fractures score 1 , burst fractures 2, translational/rotation injuries 3 and distraction injuries 4. Patients that are neurologically intact score 0, nerve root or complete spinal cord injuries 2 and incomplete injuries 3. The posterior ligamentous component scores 0 if the ligament is intact, 2 if it is suspected and 3 if it is confirmed.
Patients with a score of < 3 are considered not to be operative candidates, and those with scores > 5 are considered for surgery.
1. Lee JY, Vaccaro A, Lim MR et al. Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma. J Orthop Sci 2005;10(6):671–675.
Neurological injury
Neurological injury can be classified as ‘complete’ or ‘incomplete’. Incomplete injuries have a better potential for recovery. Various patterns of incomplete injury have been described:
Anterior cord syndrome – Loss of motor function with sparing of proprioception and pressure sensation (poor prognosis).
Posterior cord syndrome – Rare, there is loss of proprioception and pressure sensation but no motor loss (prognosis for recovery is relatively good).
Central cord syndrome – This is the most common with mixed motor and sensory loss typically greater in upper than lower limbs (prognosis for recovery is fair).
Brown–Sequard (hemicord) syndrome – Ipsilateral motor function and contralateral pain and temperature sensation. Commonly caused by penetrating injury and carries the best prognosis.
Complete injuries have no function below a certain level. The ‘level’ of the injury is determined by distal-most level with intact motor and sensory function (power 3/5, sensation 2/2 – intact light touch). Frankel grading system:
-
– Complete paralysis.
-
– Sensory preservation below level of injury – no voluntary motor function.
-
– Sensory preservation below level of injury – useless motor function.
-
– Sensory preservation below level of injury – useful voluntary motor function.
-
– Normal function.
Specific fractures
Occipital condyle fractures: Rare, mostly detected on CT, associated with cranial nerve dysfunction. Classified by Anderson and Montesano ( Type I comminuted axial impact fracture, Type II continuous with base of skull fracture, Type III avulsion at the attachment of the alar ligament). Treatment for types I and II is a cervical collar. Type III treated with halo vest or with occipitocervical fusion.
Atlanto-occipital joint subluxation: Rare,
Powers’ ratio defines subluxation (> 1 anterior subluxation < 1 posterior). Treatment is with halo-vest.
C1 (Atlas) fractures: Commonly associated with other injuries. Widening of lateral masses on ‘openmouth’ view or CT. Classified by Levine and Edwards into Type I posterior arch fractures, Type II lateral mass fractures and Type III burst fractures ( also known as Jefferson fractures). Treatment is with halo-vest immobilization.
C2 (Axis) fractures: two main groups
Anterior odontoid peg (Dens) fractures have been classified by Anderson and D’Alonzo into three types that guide treatment.
-
Fracture of the tip – treat symptomatically.
-
Fracture of the base of the odontoid. High rate of non-union. Treatment is either posterior stabilization or odontoid screw fixation. (Consider halo-vest immobilization if minimally displaced.)
-
Fracture through vertebral body. Management is usually with a halo vest.