Spinal Fracture: Traumatology and Orthopedics

• Traumatology and Orthopedics
• Instructor: Dr. Alvarez Cano
• Topic: Spinal Fracture
• Members of Group 8-4: Beltran Tostado Jesus Arath, Rodríguez Osuna Itzel Guadalupe, Tirado Contreras Angel Noel

Epidemiology

• Approximately 11,000 new spinal cord injuries requiring treatment occur each year.
• Spinal fractures account for about 6% of all fractures.
• 15% to 20% of vertebral fractures occur at multiple non-adjacent levels.
• Traffic accidents account for over 50% of traumatic spinal cord injuries.
• The overall mortality in patients with spinal cord injury during initial hospitalization is 17%.
• Approximately 2% to 6% of polytrauma patients have a cervical spine fracture.
• The ratio of men to women in vertebral fractures is 4:1.

Anatomy

• At the level of the atlas (C1), the spinal cord occupies about 35% of the vertebral canal.
• Occupies 50% in the lower cervical spine and thoracolumbar segments.
• The epidural fat, cerebrospinal fluid, and dura mater occupy the rest of the canal.
• The conus medullaris is the distal end of the spinal cord.
• Contains the sacral and coccygeal myelomeres, located behind the L1 vertebral body and the L1-2 intervertebral disc.
• The cauda equina represents the motor and sensory roots of the lumbosacral myelomeres.
• These roots are less likely to be injured because they have more space in the canal and are not anchored to it as much as the spinal cord.
• A reflex arc is a simple sensory-motor pathway whose function is separate from the long ascending and descending pathways.

Injury Mechanism

• Primary injury refers to tissue destruction caused by the applied force.

Primary Injury

• Contusion that is a sudden, minor compression displacement of a structure that initially affects the central tissues.
• It accounts for most primary injuries and neurological deficits.
• Although potentially reversible, it can cause irreversible neuronal death associated with vascular injury and intramedullary hemorrhage.
• Laceration: Caused by penetration of foreign bodies, projectile fragments, or displaced bone fragments.
• Compression is produced by a reduced spinal canal size due to translation or angulation of the spine or burst fractures.
• It can also be caused by epidural hematoma formation.
• Mechanical deformation interrupts axonal flow.
• It also interrupts the spinal cord's vascularization, causing ischemia of nervous structures.
• Stretching results from longitudinal traction (as in flexion-distraction fractures).
• The lesion occurs due to the collapse of vessels and axons due to tension distortion.

Secondary Injury

• Secondary injury refers to additional injury to nerve tissue due to the biological response initiated by the initial tissue destruction.
• Local tissues undergo structural and chemical changes that produce systemic responses.
• Reactions include tissue edema, changes in initial blood flow, and concentration changes of chemical metabolites and mediators.
• These provoke interdependent reactions, amplifying tissue destruction and functional loss.

Clinical Assessment

• Medical history includes mechanism of injury (accident, fall, impact, physical exertion, etc.).
• Symptoms include localized and radiating pain, loss of strength, and loss of sensation.
• Medical history: includes osteoporosis, cancer, bone diseases, and previous fractures.
• Must pay special attention to life-threatening injuries.
• Assess the patient's level of consciousness.
• Evaluate cranial, thoracic, abdominal, pelvic, and spinal injuries.
• Protect the spine throughout the treatment of the polytrauma patient.
• Check the skin for hematomas and abrasions, and palpate the spinous processes to detect pain or separation.

Spinal Shock:

• Spinal Shock is an alteration in spinal cord function due to neurological dysfunction rather than structural injury.
• Resolution can be recognized when caudal reflexes at the lesion level resume within 24 hours of injury.

Neurogenic Shock:

• Refers to flaccid paralysis with loss of reflexes and sensitivity.
• Due to the "cessation of activity" of the spinal cord in response to injury.
• More prevalent in cervical and upper thoracic injuries.
• Almost always resolves within the first 24 to 48 hours.
• Treatment is based on administering isotonic fluids, with careful fluid balance.
• Hypovolemia should be avoided.

Neurogenic Shock vs Spinal/Medullar Shock:

• Neurogenic shock: distributive shock.
• Triad: hypotension, bradycardia, and peripheral vasodilation.
• Spinal shock: transient loss of all spinal cord function (flaccid paralysis). Associated with segmental, polysynaptic reflexes and autonomic function.

Bulbocavernosus Reflex

• The bulbocavernosus reflex is the anal sphincter contraction in response to stimulation of the vesical trigone.
• Stimulated through compression of the glans, percussion on the mons pubis, or traction of a vesical probe.
• Absence indicates spinal shock. Recovery signals spinal shock is ending.
• The recovery of the bulbocavernosus reflex indicates that the spinal shock has ended, which generally occurs within the first 24 hours after the initial injury.
• The presence of a complete injury after the shock is resolved means that neurological recovery is impossible.

Imaging Evaluation

• Lateral projection of the cervical spine is systematic in the standard evaluation of patients.
• Complete radiographic evaluation, including anterior-posterior projections in all patients with neck pain.
• Doctors recommend lateral projection when limited by neurological injury or associated injuries.
• An MRI is helpful in evaluating spinal cord or nerve root injuries and the severity of canal compromise.

Classification

• It describes severity and pattern of neurological dysfunction.
• Complete and incomplete spinal cord injury describes degree of injury.
• Syndromes with different types of spinal cord injuries: anterior cord syndrome, central cord syndrome and Brown-Séquard syndrome. These reference patterns of neurological deficit observed during clinical evaluation.

Complete Spinal Cord Injury

• Complete loss of sensation and voluntary motor function below the level of the injury, with intact bulbocavernosus reflex.
• (Sacral levels are considered to be S2, 3 and 4.)
• Reflexes return below the level of the spinal cord injury.
• The injury level is defined by the last spinal cord level with partial neurological function retained.
• Further recovery is unlikely; the prognosis for recovery is very poor.

Incomplete Spinal Cord Injury

• Some neurological function remains below the level of the injury after bulbocavernosus reflex recovery.
• Prognosis improves with greater function below the injury and more rapid recovery.
• Preservation of sacral function indicated by anal sensation, voluntary rectal motor function, and flexor activity of the large toe.
• These indicate partial continuity in long tracts, implying continuity between the cerebral cortex and lower motor neurons.

Patterns of Incomplete Spinal Cord Injury

• Brown-Séquard Syndrome: A hemisection of the spinal cord.
• Exhibits muscular paralysis ipsilateral to the lesion, loss of proprioception, and loss of sensitivity to light touch.
• Includes contralateral hyperesthesia to pain and temperature.
• It has a good prognosis; over 90% of patients regain bowel control and bladder control.
• Most patients regain the ability to ambulate.
• Central Cord Syndrome is a frequent syndrome.
• It is common in the elderly with osteoarthritis of the spine, and is commonly associated with hyperextension injuries.
• It presents as flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities.
• Radiographs often show no fracture or dislocation because the lesion results from a pinch effect.
• Acceptable prognosis; 50-60% of patients recover motor and sensory function in the lower extremities.
• Anterior Cord Syndrome is habitual in the patient.
• It involves motor loss with loss of pain and temperature, and preservation of light touch and conscious proprioception.
• Prognosis is positive with improvement in the first 24 hours.
• Sacral sparing is generally positive for future recovery.

Spinal Cord Syndromes

• Posterior Cord Syndrome involves a sensory loss but motor function may remain intact.
• With deficits in pain and temperature, and preservation of light touch and proprioception The prognosis is good if recovery is apparent and progressive within 24 hours. The lack of sacral temperature sensation past 24 hours suggests very poor results.

Grade of Spinal Cord Injury

• Frankel Classification: used to grade the severity of spinal cord injury.
• Grade A: Absence of motor and sensory function.
• Grade B: Absence of motor function; sensory function intact.
• Grade C: Motor function present, but not useful (2/5 or 3/5); sensory function intact.
• Grade D: Motor function present and useful (4/5); sensory function intact.
• Grade E: Normal motor (5/5) and sensory functions.

ASIA (American Spinal Injury Association) Impairment Scale

• Grade A: Complete with both motor and sensory function absent in sacral segments S4-5.
• Grade B: Incomplete with sensory but no motor function preserved below the neurological level and including sacral segments S4-5. -Grade C: Incomplete with motor function preserved below the neurological level, and greater than half of key muscles below the defined neurological level have a muscle grade less than 3.
• Grade D: Incomplete with motor function preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
• Grade E: Normal as motor and sensory functions are normal.

Treatment

• Immobilization
• A rigid cervical collar should be used until the injury confirmed through clinical and radiographic evaluation.
• In children, use a backboard with a head recess of greater proportional size to accommodate occiput prominence.
• To reduce pressure ulcers, remove the patient from the rigid support.
• Turn the patient as soon as possible.

Medical Treatment of Acute Spinal Cord Injury

• Intravenous Methylprednisolone
  • Can improve recovery from neurological injury.
  • Considered the standard treatment for spinal cord injuries
  • Administration of intravenous methylprednisolone within the first 8 hours after injury to improve motor recovery in full and partially spinal cord injury. Intravenous Methylprednisolone
  • Benefits do not persist if treatment is initiated beyond 8 hours after injury.
  • Not indicated in pure root injuries.
• Ganglioside
  • Glucolipid membrane that, when administered within 72 hours of injury, achieves a significant increase in motor scores.
  • Administer 100 mg/day for 32 days after injury.
  • Simultaneous use with methylprednisolone is not recommended.

Complications

• Gastrointestinal: regurgitation and aspiration and hemorrhagic gastritis.
• Urological: Recurrent infections of the urinary tract and low diuresis.
• Pulmonary: Only the diaphragm is used for inspiration because the abdominal and intercostal muscles are paralyzed.
• Patients cannot cough or clear lung secretions, with pulmonary edema resulting.
• All of this can cause High rates of morbidity and mortality due to pulmonary complications.
• Cutaneous: pressure ulcers.

Ruling Out Spine Injuries

• Screening for suspected spine injuries involves detailed evaluation.
• Ensures no vertebral injury requires treatment is present.
• Anamnesis to evaluate high-risk situations and factors.
• Exploration for signs of vertebral lesion or neurological deficit.
• Imaging based on initial valuation.

Clinical Criteria for Ruling Out Spinal Injuries:

• Absence of midline spinal pain when palpated.
• Full range of active and pain-free neck movement.
• Absence of focal neurological deficits.
• Normal level of alertness.
• No evidence of intoxication.
• Absence of distracting injuries.

Explore spinal fractures in this lesson from Dr. Alvarez Cano's Traumatology and Orthopedics class. We'll cover the epidemiology of spinal fractures, including incidence rates, common causes like traffic accidents, and mortality rates. Also reviews the relevant anatomy of the spinal column.