Spine Injuries – General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries PDF

| 14.02.23 - 13:47 1118 Spine Trauma 68 Spine Injuries – General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries 68.1 Introduction 20% of patients with a major spine injury will have a second spinal injury at another level, which may be noncontig...

| 14.02.23 - 13:47 1118 Spine Trauma 68 Spine Injuries – General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries 68.1 Introduction 20% of patients with a major spine injury will have a second spinal injury at another level, which may be noncontiguous. These patients often have simultaneous but unrelated injuries (e.g., chest trauma, TBI…). Injuries directly associated with spinal cord injuries include arterial dissections (carotid and/or vertebral arteries). 68.2 Terminology 68.2.1 Spinal stability 68 Many definitions have been proposed. A conceptual definition of clinical stability from White and Panjabi1: the ability of the spine under physiologic loads to limit displacement so as to prevent injury or irritation of the spinal cord and nerve roots (including cauda equina), and to prevent incapacitating deformity or pain due to structural changes. Biomechanical stability refers to the ability of the spine ex vivo to resist forces. Predicting spinal stability is often difficult, and to this end various models have been developed, none of which is perfect. See models of stability for cervical spine injuries (p. 1182) and thoracolumbar fractures (p. 1200). 68.2.2 Level of injury There is disagreement over what should be defined as “the level” of a spinal cord injury. Some define the “level” of a spinal cord injury as the lowest level of completely normal function (thus a patient would be termed a C5 quadriplegic even with minor C6 motor function). However, most sources define the “level” as the most caudal segment with motor function that is at least 3 out of 5 and if pain and temperature sensation is present. 68.2.3 Completeness of lesion Categorization is important for treatment decisions and prognostication. Incomplete lesion Definition: any residual motor or sensory function more than 3 segments below the level of the injury.2 Look for signs of preserved long-tract function. Signs of incomplete lesion: 1. sensation (including position sense) or voluntary movement in the LEs in the presence of a cervical or thoracic spinal cord injury 2. “sacral sparing”: preserved sensation around the anus, voluntary rectal sphincter contraction, or voluntary toe flexion 3. an injury does not qualify as incomplete with preserved sacral reflexes alone (e.g., bulbocavernosus) Types of incomplete spinal cord injury: 1. central cord syndrome (p. 1132) 2. Brown-Séquard syndrome (cord hemisection) (p. 1135) 3. anterior cord syndrome (p. 1135) 4. posterior cord syndrome (p. 1136): rare Complete lesion No preservation of any motor and/or sensory function more than 3 segments below the level of the injury in the absence of spinal shock (see below). About 3% of patients with complete injuries on initial exam will develop some recovery within 24 hours. Recovery is essentially zero if the spinal cord injury remains complete beyond 72 hours. https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1119 Spinal shock This term is often used in two completely different senses: ● 1st SENSE: hypotension (shock) that follows spinal cord injury (SBP usually ≈ 80 mm Hg). See Hypotension (p. 1139) for treatment. Caused by multiple factors: a) interruption of sympathetics: implies spinal cord injury above T1 ○ loss of vasoconstrictors → vasodilatation (loss of vascular tone) below the level of injury ○ leaves parasympathetics relatively unopposed causing bradycardia b) loss of muscle tone due to skeletal muscle paralysis below level of injury results in venous pooling and thus a relative hypovolemia c) blood loss from associated wounds → true hypovolemia ● 2nd SENSE: transient loss of all neurologic function (including segmental and polysynaptic reflex activity and autonomic function) below the level of the SCI3,4 → flaccid paralysis and areflexia a) duration: may abate in as little as 72 hours, but typically persists 1–2 weeks, occasionally several months b) accompanied by loss of the bulbocavernosus reflex c) spinal cord reflexes immediately above the injury may also be depressed on the basis of the Schiff-Sherrington phenomenon (primarily described in animal models) d) when spinal shock resolves, there will be spasticity below the level of the lesion and return of the bulbocavernosus reflex e) a poor prognostic sign 68 68.3 Whiplash-associated disorders 68.3.1 General information “Whiplash” was initially a lay term, which is currently defined as a traumatic injury to the soft tissue structures in the region of the cervical spine (including: cervical muscles, ligaments, intervertebral discs, facet joints…) due to hyperflexion, hyperextension, or rotational injury to the neck in the absence of fractures, dislocations, or intervertebral disc herniation.5 It is the most common non-fatal automobile injury.6 Symptoms may start immediately, but more commonly are delayed several hours or days. In addition to symptoms related to the cervical spine, common associated complaints include headaches, cognitive impairment, and low back pain. 68.3.2 Clinical grading A proposed clinical classification system of WAD is shown in ▶ Table 68.1.7 Table 68.1 Clinical grading of WAD severity Grade Whiplash athe Description 0 no complaints, no signsa 1 neck pain or stiffness or tenderness, no signs 2 above symptoms with reduced range of motion or point tenderness 3 above symptoms with weakness, sensory deficit, or absent deep tendon reflexes 4 above symptoms with fracture or dislocationa definition of whiplash excludes these patients5 68.3.3 Evaluation and treatment A consensus8 regarding diagnosis and management of these injuries is shown in ▶ Table 68.2 and ▶ Table 68.3. Keep in mind that conditions such as occipital neuralgia may occasionally follow whiplash-type injuries and should be treated appropriately (▶ Table 68.3). Table 68.2 Evaluation of WAD Grade 1: patients with normal mental status and physical exam do not require plain radiographs on presentation Grade 2 & 3 patients: C-spine X-rays, possibly with flexion-extension views. Special imaging studies (MRI, CT, myelography…) are not indicated Grade 3 & 4: these patients should be managed as suspected spinal cord injury; see Initial management of spinal cord injury (p. 1138) and sections that follow https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 1120 Spine Trauma Table 68.3 Treatment of WAD8a Whiplash is usually a benign condition requiring little treatment and usually resolves in days to a few weeks in most cases. Recommendation Grade 1 Range of motion exercises 68 2 3 should be started immediately for all Encourage early return to regular activities immediately ASAP Cervical collars and restb no not for > 72 hrs Passive modality therapies: heat, ice, massage, TENS, ultrasound, relaxation techniques, acupuncture, and work alteration no optional if symptoms last > 3 wks Medications: optional use of NSAIDs and nonnarcotic analgesics? (recommended for ≤ 3 wks) no yes yes. Limited narcotics may also occasionally be needed Surgery no no only for progressive neurologic deficit or persisting arm pain not for > 96 hrs ✖ Not recommended: cervical pillows and soft collars, bed rest, spray and stretch exercises, muscle relaxant medication, TENS, reflexology, magnetic necklaces, herbal remedies, homeopathy, OTC medications (except NSAIDs, see above), and intra-articular, intrathecal, or trigger point steroid injections aexcluding patients with fractures, dislocations, or spinal cord injuries bsoft foam collars are generally discouraged; if they are to be used, the narrow part should be placed in front to avoid neck extension5 68.3.4 Outcome In a study of 117 patients < 56 years of age having WAD due to automobile accidents (excluding those with cervical fractures, dislocations, or injuries elsewhere in the body) conducted in Switzerland9 (where all medical costs were paid by the state and there was no opportunity for litigation and no compensation for pain and suffering, although there was the possibility of permanent disability), the recovery rate was as shown in ▶ Table 68.4. Of the 21 patients with continued symptoms at 2 yrs, only 5 were restricted with respect to work (3 reduced to part-time work, 2 on disability). Patients with persistent symptoms were older, had more varied complaints on initial exam, had a more rotated or inclined head position at the time of impact, had a higher incidence of pretraumatic headaches, and had a higher incidence of certain pre-existing findings (such as radiologic evidence of cervical osteoarthritis). The amount of damage to the automobile and the speed of the cars had little relationship to the degree of injury, and outcome was not influenced by gender, vocation, or psychological factors. Table 68.4 Recovery of patients with WAD Time (mos) Percent recovered 3 56% 6 70% 12 76% 24 82% https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1121 68.4 Pediatric spine injuries 68.4.1 General information Key concepts ● ● ● ● ● ● until age ≈ 16, spinal cord injury is relatively infrequent ligamentous injuries are more common than actual fractures due to flexibility of ligamentous spine/spinal cord injuries that are somewhat unique to the pediatric population a) atlantooccipital dislocation (AOD) (p. 1153): a retroclival hematoma should raise the index of suspicion for AOD b) SCIWORA (p. 1196) (spinal cord injury without radiographic abnormality) c) synchondrosis fractures: os odontoideum (p. 1175), C2 synchondrosis d) atlantoaxial rotatory fixation/subluxation (p. 1158) when AOD is a consideration, cervical CT is the imaging modality of choice to measure the condyle-C1 interval (CCI) most stable fractures and ligamentous injuries may be treated nonsurgically. C2 synchondrosis fractures are ususally managed with halo traction surgical challenges include: finding hardware small enough for young children, the small size of C-spine lateral masses, and difficulty thoroughly removing disc material and cartilage Spinal cord injury is fairly uncommon in children; the ratio of head injuries to spinal cord injuries is ≈ 30:1 in pediatrics. Only ≈ 5% of spinal cord injuries occur in children. Due to ligamentous laxity together with a high head-to-body weight ratio, immaturity of paraspinal muscles and the underdeveloped uncinate processes, these tend to involve ligamentous rather than bony injuries (e.g., SCIWORA (p. 1196)). There is also the potential for physeal (growth plate) separation in young children, which may have good potential to heal. The cervical spine is the most vulnerable segment (with subaxial injuries being fairly uncommon), with 42% of injuries occurring here, 31% thoracic, and 27% lumbar. The fatality rate is higher with pediatric spine injuries than with adults (opposite to the situation with head injury), with the cause of death more often related to other severe injuries than to the spinal injury.10 68.4.2 Pediatric cervical spine injuries and mimics General information See pediatric C-spine anatomy (p. 224). In the age group ≤ 9 yrs, 67% of cervical spine injuries occur in the upper 3 segments of the cervical spine (occiput-C2).11 Synchondroses Normal synchondroses (p. 226) may be mistaken for fractures, especially the dentocentral synchondrosis of the axis (p. 224) which may be mistaken for an odontoid fracture. Conversely, synchondroses are biomechanically weak links and actual fractures may occur through them (▶ Fig. 68.1).12,13 C2 is the most common vertebra injured in children. ▶ Odontoid epiphysiolysis. A fracture through the dentocentral synchondrosis (much of the literature says neurocentral synchondrosis, but I believe that is incorrect). Mimics an odontoid type II fracture. 23% will develop neurologic deficit, and in 53% of these the SCI level occurs lower at the cervicothoracic junction.14 Recommended treatment for fractures through synchondroses: the tendency for synchondroses to fuse suggests that emergency reduction followed by external immobilization should be attempted. For C2, a halo is recommended, with 80–90% success rate.12,14 Internal immobilization/fusion should be reserved for persistent instability13 after 3–6 months.14 Evaluation General information Practice guidelines for diagnostic workup are shown below (see Practice guideline: Evaluation of pediatric C-spine injuries (p. 1122)). Retroclival hematoma (p. 1102) on imaging should prompt immobilization and evaluation for atlantooccipital dislocation (AOD). https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1122 Spine Trauma Fig. 68.1 Fracture through C2 dentocentral synchondrosis (odontoid epiphysiolysis). Sagittal cervical CT in 23-month-old injured in motor vehicle crash. Note anterior angulation of the odontoid process and several mm of separation from the main C2 vertebral body. fracture 68 Practice guideline: Evaluation of pediatric C-spine injuries Level I15 ● Use CT to assess the condyle-C1 interval (CCI) (p. 1154) (AKA atlantooccipital interval) for pediatric patients with potential atlantooccipital dislocation (AOD) Level II15: Do not perform C-spine imaging in children > 3 years of age with trauma who are: ○ alert ○ neurologically intact ○ without posterior midline cervical tenderness (with no distracting pain) ○ not hypotensive without explanation ○ not intoxicated ● Do not perform C-spine imaging in children < 3 years of age with trauma who meet all of the following conditions: ○ have a GCS > 13 ○ are neurologically intact ○ have no cervical midline tenderness (without distracting injury) ○ are not intoxicated ○ do not have unexplained hypotension ○ were not in a motor vehicle collision, a fall > 10 feet, or non-accidental trauma (NAT) as the known or suspected mechanism of injury ● Obtain cervical spine X-rays or high-resolution cervical CT in pediatric trauma victims who do not meet either set of criteria above ● Obtain 3-position CT with C1–2 motion analysis to confirm and classify the diagnosis for children suspected of having atlantoaxial rotatory fixation (AARF) ● https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1123 Pseudospread of the atlas Pseudospread of the atlas is defined as > 2 mm total overlap of the two C1 lateral masses on C2 on AP open-mouth view.16 This could be misdiagnosed as a Jefferson fracture (p. 1162), which rarely occurs prior to the teen-ages (owing to lower weight of children, more flexible necks, increased plasticity of skull, and shock absorbing synchondroses of C1). Pseudospread is probably a result of disproportionate growth of the atlas on the axis. It is present in most children 3 mos to 4 yrs of age. Prevalence is 91–100% during the second year of life. Youngest example at 3 mos, oldest at 5.75 yrs. Normal total offset is typically 2 mm during the first year, 4 mm during the second, 6 mm during the third, and decreasing thereafter. The maximum is 8 mm. Trauma is not a contributing factor. Neck rotation can also sometimes simulate the appearance of a Jefferson fracture. When suspicion of a Jefferson fracture is high: thin cut CT scan parallel to and through C1 can resolve the issue of whether or not there is a fracture. Pseudosubluxation Anterior displacement and/or significant angulation, usually of C2 (axis) on C3 (▶ Fig. 68.2) (occasionally C3 on C4) on lateral C-spine X-rays or sagittal imaging (CT or MRI) that may occur normally in children (up to age 10 yrs, sometimes persisting up to age 1417). When identified after trauma, this may be misinterpreted as a traumatic injury. Fractures and dislocations are unusual in children, and when they do occur, they resemble those in adults. C2 C3 posterior anterior Fig. 68.2 Pseudosubluxation of C2 anteriorly on C3 (yellow arrowhead). Image: sagittal cervical CT scan bone window in a 4-yearold girl. Physiology: flexion and extension are initially centered at C2–3, this gradually moves down to C4–5 or C5–6 usually by age 10 yrs. C2 normally moves forward on C3 up to 2–3 mm in peds.18 Forward displacement on neck flexion may be exacerbated by paraspinal spasm at lower levels.19 It does not represent pathological instability. 10 cases reported between ages 4–6 yrs20: pain was not uncommon. In each case, either the head or neck was flexed (sometimes minimally); the pseudosubluxation corrected when X-ray was repeated with head in true neutral position. However, this does not rule out instability. True subluxation may occur with: 1. fractures (e.g., hangman’s fracture (p. 1165)) which allow the C2 VB to move forward without a corresponding displacement of the posterior elements of C2. This may be suspected on plain Xrays with C2-3 subluxation when the base of the C2 spinous process is 1.5 mm posterior to the posterior cervical line of Swischuk (▶ Fig. 12.1),21 and is assumed to be present when ≥ 2 mm posterior.17,21 CT scan is diaagnostic 2. injury to the C2-3 disc and posterior elements: may be demonstrable on STIR MRI (p. 241) https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1124 Spine Trauma Treatment Practice guideline: Treatment of pediatric C-spine injuries Level III15: ● children < 8 yrs of age: when restrained, immobilize with thoracic elevation or an occipital recess (allows more neutral alignment due to the relatively large head) ● children < 7 yrs of age with injuries of the C2 synchondrosis (p. 226): closed reduction and halo immobilization ● patients with atlantoaxial rotatory subluxation/fixation (AARF): ○ acute AARF (< 4 weeks duration) that does not reduce spontaneously: reduction with manipulation or halter traction ○ chronic AARF (> 4 weeks duration): reduction with halter or tong/halo traction ○ recurrent or irreducible AARF: internal fixation and fusion ● for isolated cervical spine ligamentous injuries and unstable or irreducible fractures of dislocations with associated deformity: consider primary operative treatment ● for cervical spine injuries that fail non-operative management: operative treatment 68 Assessment tools for spinal stability used in adults have not been validated in the pediatric population. 68.5 Cervical bracing 68.5.1 Soft collars Soft (sponge rubber) collar: does not immobilize the cervical spine to any significant degree. Its function is primarily to remind the patient to reduce neck movements. 68.5.2 Rigid cervical collars Inadequate for stabilizing upper and mid-cervical spine and for preventing rotation. Common rigid collars: ● Miami J collar & Aspen collar: have removable pads ● Philadelphia collar: no removable pads. Feels hotter to wear 68.5.3 Poster braces Distinguished from cervicothoracic orthoses (see below) by the lack of straps under the axilla. Includes the four poster brace. Generally good for preventing flexion at midcervical levels. 68.5.4 Cervicothoracic orthoses Cervicothoracic orthoses (CTO) incorporate some form of body vest to immobilize the cervical spine. The following are presented in increasing degree of immobilization. Guilford brace: essentially a ring around the occiput and chin connected by two posts to anterior and posterior thoracic pads. SOMI brace: acronym for Sternal Occipital Mandibular Immobilizer. Good for bracing against flexion (especially upper cervical spine). Inadequate for hyper-extension type injuries because of weak occipital support. Has special forehead attachment to allow patient to eat comfortably without mandibular support. “Yale brace”: a sort of extended Philadelphia collar. The most effective CTO for bracing against flexionextension and rotation. Major shortcoming is poor prevention of lateral bending (only ≈ 50% reduced). 68.5.5 Halo-vest brace Can immobilize the upper or lower cervical spine, not very good for mid-cervical spine (due to snaking of the midcervical spine). Unable to provide adequate distraction support following vertebral body resection when patient assumes upright position (i.e., it is not a portable cervical traction device). Overall reduction of flexion/extension as well as lateral bending is ≈ 90–95%, rotation is reduced by 98%. See placement (p. 1147). https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1125 68.6 Follow-up schedule After initial management (surgical or nonsurgical) of cervical spine problems (stable or unstable), the follow-up schedule shown in ▶ Table 68.5 is suggested to permit recognition of problems in time for treatment1 (start with 3 weeks and keep doubling the interval to 1 year). Table 68.5 Sample follow-up cervical spine clinic visit schedule Time post-op Agenda 7–10 days (for post-op patients only) wound check, D/C sutures/staples if used 4–6 weeks AP & lateral C-spine X-ray in brace (no flexion/extension) to rule out instability or progression of fracture(s) 10–12 weeks ● ● 6 months ● ● 1 year (optional) ● ● AP & lateral C-spine X-rays with flexion/extension views out of brace if X-rays show no instability or progression of fracture(s) and patient is doing well, begin weaning brace AP & lateral C-spine X-rays with flexion/extension views some surgeons release patients at this time if they are doing well AP & lateral C-spine X-rays with flexion/extension views release patient if they are doing well 68.7 Sports-related cervical spine injuries 68.7.1 General information Any of the spine injuries described in this book can be sports-related. This section considers some injuries peculiar to sports. Bailes et al22 classified sports-related spinal cord injuries (SCI) as shown in ▶ Table 68.6. Type I injures may be complete or may have features of any of the incomplete SCI syndromes (often in mixed or partial forms). Type II injuries include spinal concussion, spinal neuropraxia (see below), and the burning hands syndrome (see below), all in the absence of radiographic abnormalities and all with complete resolution of symptoms. Patients should be carefully evaluated, and return to competition should not be allowed in the presence of neurologic deficit, radiographically demonstrated injury, certain congenital C-spine abnormalities, and possibly for “repeat offenders” (p. 1126). Type III injuries are the most common. Unstable injuries should be treated appropriately (p. 1194). Table 68.6 Sports-related spinal cord injuries Type Description I permanent SCI II transient SCI without radiographic abnormality III radiologic abnormality without neurologic deficit 68.7.2 Football-related cervical spine injuries General information ✖ Football players with suspected C-spine injury should not have their helmet removed in the field (p. 1138). Terminology The following terms probably originated as locker-room jargon for various cervical spine-related injuries usually sustained in playing football. Medical definitions have subsequently been retrofitted to them. As a result, the precise definitions may not be uniformly agreed upon. Although the semantics may differ, it is more important from a diagnostic and therapeutic standpoint to distinguish nerve root injuries, brachial plexus injuries, and spinal cord injuries. 1. cervical cord neuropraxia23 (CCN): sensory changes that may involve numbness, tingling or burning. May or may not be associated with motor symptoms of weakness or complete paralysis. Typically lasts < 15 mins (although may persist up to 48 hrs), involves all 4 extremities in 80% of cases. Narrowing of the sagittal diameter of the cervical spinal canal is felt to be a contributory https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1126 Spine Trauma factor. With resumption of contact activities, recurrence rate is ≈ 56%, with higher risks of recurrence among those with narrower canal diameters. Evaluation should include cervical MRI. Torg23 feels that uncomplicated cases of CCN (no spinal instability and no MRI evidence of cord defect or edema) have a low risk of permanent injury and does not recommend activity restrictions 2. “stinger” or “burner”: distinct from the burning hands syndrome. Unilateral, burning dysesthetic pain radiating down one arm from the shoulder, sometimes associated with weakness involving the C5 or C6 nerve roots. Usually follows a tackle. May result from downward traction on the upper trunk of the brachial plexus (when the shoulder is forcefully depressed with the neck flexed to the contralateral side) or by direct nerve root compression in the neural foramina (not an SCI) 3. burning hands syndrome24: similar to a stinger, but bilateral. Probably represents an SCI; possibly a mild variant of a central cord syndrome (p. 1132) 4. other neurologic injuries include: vascular injury to carotid or vertebral arteries. Usually related to intimal dissection (p. 1220) following a direct blow to the neck or by extreme movements. Symptoms are those of a TIA or stroke Spear tackler’s spine 68 Rule changes in 1976 banned spearing (the practice of using the football helmet as a battering ram to tackle an opponent) and resulted in a reduction of the number of football-related occurrences of cervical spine fractures and quadriplegia.25 Four characteristics of spear tackler’s spine: 1. cervical spinal stenosis 2. loss of normal cervical lordosis: as a result, the stress of axial loading is more likely to be imparted to the vertebral bodies, rather than being absorbed by the cervical musculature and ligaments, increasing the risk of burst fractures and quadriplegia 3. evidence of pre-existing traumatic abnormalities 4. documented spear tackler’s technique Suggested management: The athlete is removed from competition until the cervical lordosis returns and the player learns to use other tackling techniques. This tackling technique has been banned since 1976. 68.7.3 Return to play and pre-participation guidelines Return to play (RTP) and pre-participation evaluation guidelines related to the cervical spine are shown in ▶ Table 68.7 (modified26). These are just guidelines, and do not ensure safety. Clinical judgment must always be employed. Table 68.7 C-spine-related contraindications for participation in contact sportsa Conditionb C.I.c Congenitald 1. 2. 3. odontoid abnormalities (serious injury may result from atlanto-axial instability) a. complete aplasia (rare) absolute b. hypoplasia (seen in conjunction with achondroplasia and spondyloepiphyseal dysplasia) absolute c. os odontoideum (probably of traumatic origin) absolute atlantooccipital fusion (partial or complete fusion of atlas to occiput): sudden onset of symptoms & sudden death have been reported absolute Klippel-Feil anomaly (congenital fusion of 2 or more cervical vertebrae)e a. Type I: mass fusion of C-spine to upper T-spine b. Type II: fusion of only 1 or 2 interspaces absolute ● associated with limited ROM, occipitocervical anomalies, instability, disc disease or degenerative changes absolute ● associated with full ROM and none of the above none (continued) https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1127 Table 68.7 continued Conditionb C.I.c Acquired 1. cervical spinal stenosisf a. asymptomatic none b. with one episode of cord neuropraxia relative c. cord neuropraxia + MRI evidence of cord defect or edema absolute d. cord neuropraxia + ligamentous instability, symptoms or neurologic findings > 36 hrs, or multiple episodes absolute 2. spear tackler’s spine (see text) absolute 3. spina bifida occulta: rare, incidental X-ray finding none Posttraumatic upper cervical spine 1. atlantoaxial instability (ADI > 3 mm adults, > 4 mm peds) absolute 2. atlantoaxial rotatory fixation (may be associated with disruption of transverse ligament) absolute 3. fractures 4. a. healed, pain-free, full ROM, & no neurologic findings with any of the following fractures: nondisplaced Jefferson fracture; odontoid fracture; or lateral mass fracture of axis none b. all others absolute post-surgical atlantoaxial fusion absolute Posttraumatic subaxial cervical spine 1. ligamentous injuries: > 3.5 mm subluxation, or > 11° angulation on flexion-extension views 2. fractures 3. 4. absolute a. healed, stable fractures listed here with normal exam: VB compression fracture without posterior involvement; spinous process fractures none b. VB fractures with sagittal component or posterior bony or ligamentous involvement absolute c. comminuted fracture with displacement into spinal canal absolute d. lateral mass fracture producing facet incongruity absolute intervertebral disc injury a. healed herniated disc treated conservatively none b. S/P ACDF with solid fusion, no symptoms, normal exam, and full pain-free ROM none c. chronic herniated disc with pain, neuro findings or ↓ ROM, or acute herniated disc absolute S/P fusion a. stable one-level fusion none b. stable two-level fusion relative c. fusion > 2 levels absolute aorganized contact sports includes26: boxing, football, ice hockey, lacrosse, rugby & wrestling bsee also cranial-related (and craniocervical) conditions (p. 1308) (e.g., Chiari I malformation…) cC.I. = contraindications, classified as absolute, relative (i.e., uncertain) or none dcongenital abnormalities may have particular relevance to Special Olympics eNB: Klippel-Feil may be associated with abnormalities in other organ systems (e.g., cardiac) which may impact on participation in contact sports (p. 289) f Pavlov ratio (p. 1302) has a low positive predictive value for injuries in contact sports and is therefore not a useful screening test (i.e., an asymptomatic Pavlov ratio < 0.8 is not a contraindication to participation) 68.8 Neurological assessment 68.8.1 General information Evaluation of the level of the lesion requires familiarity with the following concepts about the relationship between the bony spinal canal and the spinal cord and nerves (▶ Fig. 68.3). 1. since there are 8 pairs of cervical nerves and only 7 cervical vertebra a) cervical nerves 1 through 7 exit above the pedicles of their like-numbered vertebra b) C8 exits below the C7 pedicle c) thoracic, lumbar, and sacral nerves exit below the pedicles of their like-numbered vertebra https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1128 Spine Trauma vertebral body spinal nerve C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 68 T3 T4 T5 T6 spinal cord segment spinous process C1 C1 C1 C2 C2 C2 C3 C3 C4 C3 C4 C5 C4 C5 C6 C5 C6 C7 C6 C8 C7 T1 C7 T1 T2 T1 T3 T2 T2 T4 T3 T3 T5 T4 T6 T4 T5 T7 T5 T6 T7 T7 T8 T8 T9 T9 T10 T11 L2 L3 10 T6 T7 T11 L1 T 1 0 2T 11 3 4 T 5 12 L1 conus medullaris (L1-2) L2 L3 L3 L4 L4 L4 L5 L5 T9 11 T8 12 T9 L1 L1 T8 T10 T12 T12 L2 Fig. 68.3 Relationship between spinal cord, nerve roots, and bony spine. The conus medullaris in the adult lies at about L1 or L2 of the spine (see text). The lower extent of the thecal sac is typically around S2. The C1 through C7 nerve roots exit above the pedicles of their like-numbered vertebra. Nerve roots of T1 and lower exit below the pedicles of their like-numbered vertebra. L5 S1 cauda equina terminus of thecal sac (S2) S1 S2 S3 S4 S5 Cx1 https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1129 2. due to disproportionately greater growth of the spinal column than the spinal cord during development, the following relationships of the spinal cord to the vertebral column exist: a) to determine which segment of the spinal cord underlies a given vertebra: ● from T2 through T10: add 2 to the number of the spinous process ● for T11, T12 and L1, remember that these overlie the 11 lowest spinal segments (L1 through L5, S1 through S5, and Coxygeal-1) b) the mean position of the conus medullaris (the lowest extent of the spinal cord) is attained during the first few months of life and doesn’t change.27 It is at the lower third of the L1 VB on MRI in adults (range: middle third of T12 to upper third of L3)28 68.8.2 Motor level assessment General information ▶ Table 68.8 and ▶ Table 68.9 are for rapid assessment (see ▶ Table 30.5 and ▶ Table 30.7 for detailed tables of motor innervation). Table 68.8 Key muscles for motor level classification (EXTREMITIES) RIGHT grade Segment Muscle Action to test LEFT grade 0–5 C5 biceps flex elbow 0–5 0–5 C6 wrist extensors cock up wrist 0–5 0–5 C7 triceps extend elbow 0–5 0–5 C8 flexor digitorum profundus flex middle distal phalanx 0–5 0–5 T1 hand intrinsics abduct little finger 0–5 0–5 L2 iliopsoas flex hip 0–5 0–5 L3 quadriceps straighten knee 0–5 0–5 L4 tibialis anterior dorsiflex foot 0–5 0–5 L5 EHL dorsiflex big toe 0–5 0–5 S1 gastrocnemius plantarflex foot 0–5 50 ← TOTAL POSSIBLE POINTS → 50 GRAND TOTAL: 100 Table 68.9 Axial muscle evaluation31 Level Muscle C4 diaphragm Action to test tidal volume (TV), FEV1, and vital capacity (VC) T2–9 T9–10 T11–12 intercostals upper abdominals lower abdominals use sensory level, abdominal reflexes, & Beevor’s sign ASIA (American Spinal Injury Association) motor scoring system A system29,30 that may be rapidly applied to grade 10 key motor segments using the MRC Grading Scale (▶ Table 30.2) from 0–5 on the left and the right, for a total score of 100 possible points (see ▶ Table 68.8). NB: most muscles receive innervation from two adjacent spinal levels, the levels listed in ▶ Table 68.8 are the lower of the two. The standard considers a segment intact if the motor grade is fair (≥ 3). For additional information, see www.asia-spinalinjury.org. More detailed motor evaluation See ▶ Table 68.10. https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1130 Spine Trauma Table 68.10 Skeletal muscles and their major spinal innervation (major contributing segment is shown in boldface) 68 Segment Muscle C1–4 neck muscles Action to test Reflex C3, 4, 5 diaphragm inspiration, TV, FEV1, VC C5, 6 deltoid abduct arm > 90° C5, 6 biceps elbow flexion C6, 7 extensor carpi radialis wrist extension supinator C7, 8 triceps, extensor digitorum elbow and finger extension triceps C8, T1 flexor digitorum profundus grasp (flex distal phalanges) C8, T1 hand intrinsics abduct little finger, adduct thumb T2–9 intercostalsa T9,10 upper abdominalsa T11, 12 lower abdominalsa L2, 3 iliopsoas, adductors hip flexion cremasteric reflexd L3, 4 quadriceps knee extension infrapatellar (knee jerk) L4, 5 medial hamstrings, tibialis anterior ankle dorsiflexion medial hamstrings L5, S1 lateral hamstrings, posterior tibialis, peroneals knee flexion L5, S1 extensor digitorum, EHL great toe extension S1, 2 gastrocs, soleus ankle plantarflexion Achilles (ankle jerk) S2, 3 flex digitorum, flex hallucis S2, 3, 4 bladder, lower bowel, anal sphincter clamp down during rectal exam anal cutaneous reflexe, bulbocavernosus & priapism Beevor’s signb biceps abdominal cutaneous reflexc aalso use sensory level to help evaluate these segments bBeevor’s sign: used to assess abdominal musculature for level of lesion. Patient lifts head off of bed by flexing neck; if lower abdominal muscles (below ≈ T9) are weaker than upper abdominal musculature, then umbilicus moves cephalad. Not helpful if both upper and lower abdominals are weak cthe abdominal cutaneous reflex: scratching one quadrant of abdomen with sharp object causes contraction of underlying abdominal musculature, causing umbilicus to migrate toward that quadrant. Upper abdominal reflex: T8–9. Lower abdominal reflex: T10–12. This is a cortical reflex (i.e., reflex loop ascends to cortex, and then descends to abdominal muscles). The presence of this response indicates an incomplete lesion for cord injuries above the lower thoracic level dcremasteric reflex: L1–2 superficial reflex eanal-cutaneous reflex: AKA anal wink. Normal reflex: mild noxious stimulus (e.g., pinprick) applied to skin in region of anus results in involuntary anal contraction. Bulbocavernosus (BC) reflex: see section 68.8.5 68.8.3 Sensory level assessment (dermatomes and sensory nerves) ASIA standards.29 28 key points identified in ▶ Table 68.11 are scored separately for pinprick and light touch on the left & right side using the grading scale shown in ▶ Table 68.12, for a maximum possible total of 112 points for pinprick (left & right) and 112 points for light touch (left & right). NB: regarding the “C4 cape” AKA “bib” region across the upper chest and back: sensory segments “jump” from C4 to T2 with the intervening levels distributed exclusively on the UEs (▶ Fig. 1.16). The location of this transition is not constant from person to person. 68.8.4 Rectal exam 1. external anal sphincter is tested by insertion of the examiner’s gloved finger a) perceived sensation is recorded as present or absent. Any sensation felt by the patient indicates that the injury is sensory incomplete b) record resting sphincter tone and any voluntary sphincter contraction 2. bulbocavernosus (BC) reflex (p. 1130); see also below: Absence suggests the presence of spinal shock, and it may not be possible to declare a suprasacral SCI as complete because there might be spinal shock which could transiently suppress spinal cord function https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1131 Table 68.11 Key sensory landmarks Level Dermatome C2 occipital protuberance C3 supraclavicular fossa C4 top of acromioclavicular joint C5 Lateral side of antecubital fossa C6 thumb, dorsal surface, proximal phalanx C7 middle finger, dorsal surface, proximal phalanx C8 little finger, dorsal surface, proximal phalanx T1 medial (ulnar) side of antecubital fossa T2 apex of axilla T3 third intercostal space (IS) T4 fourth IS (nipple line) T5 fifth IS (midway between T6 & T8) T6 sixth IS (xiphoid process) T7 seventh IS (midway between T6 & T8) T8 eighth IS (midway between T6 & T10) T9 ninth IS (midway between T8 & T10) T10 tenth IS (umbilicus) T11 eleventh IS (midway between T10 & T12) T12 inguinal ligament at mid-point L1 half the distance between T12 & L2 L2 mid-anterior thigh L3 medial femoral condyle L4 medial malleolus L5 dorsum of foot at 3rd MTP (metatarsal phalangeal) joint S1 lateral heel S2 popliteal fossa in the mid-line S3 ischial tuberosity S4–5 perianal area (taken as 1 level) Table 68.12 Sensory grading scale Grade Description 0 absent 1 impaired (partial or altered appreciation) 2 normal NT not testable 68.8.5 Bulbocavernosus (BC) reflex A polysynaptic spinal cord mediated reflex relayed via S2–4 nerve roots. Contraction of anal sphincter in response to squeezing the glans penis in males, or to tugging on the Foley catheter in either sex is a normal response (must be differentiated from the movement of the Foley catheter balloon). Loss of the bulbocavernosus (BC) reflex can occur with: 1. spinal shock: the BC reflex may be lost with spinal shock as can occur with suprasacral injuries. Reportedly, the return of the BC reflex may be the earliest clinical indicator that spinal shock has subsided 2. injuries involving the cauda equina or conus medullaris Presence of BC reflex used to be taken as an indication of an incomplete injury, but its presence alone is no longer considered to have a good prognosis for recovery. https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1132 Spine Trauma 68.8.6 Additional sensory exam The following elements are considered optional but it is recommended that they be graded as absent, impaired, or normal: 1. position sense: test index finger and great toe on both sides 2. awareness of deep pressure/deep pain 68.8.7 ASIA impairment scale The ASIA impairment scale*29 is shown in ▶ Table 68.13 (a modified Frankel Neurological Performance scale32). *NB: this scale indicates the completeness of spinal cord injury and is distinct from the other ASIA grading scales; see also motor and sensory scoring (p. 1129). Table 68.13 ASIA impairment scale 68 Class Description A complete: no motor or sensory function preserved B incomplete: sensory but no motor function preserved below the neurologic level (includes sacral segments S4–5) C incomplete: motor function preserved below the neurologic level (more than half of key muscles below the neurologic level have a muscle strength grade < 3)a D incomplete: motor function preserved below the neurologic level (more than half of key muscles below the neurologic level have a muscle strength grade ≥ 3) E afor normal: sensory & motor function returned to normal muscle strength grading, see ▶ Table 30.2 68.9 Spinal cord injuries 68.9.1 Complete spinal cord injuries See definition of complete vs. incomplete spinal cord injury (p. 1118). In addition to loss of voluntary movement, sphincter control and sensation below the level of the injury, there may be priapism (p. 1140). Hypotension and bradycardia (p. 1119) (spinal shock) may also present. 68.9.2 Bulbar-cervical dissociation Occurs as a result of spinal cord injury at or above ≈ C3 (includes SCI from atlantooccipital and atlantoaxial dislocation). Bulbar-cervical dissociation produces immediate pulmonary and, often, cardiac arrest. Death results if CPR is not instituted within minutes. Patients are usually quadriplegic and ventilator dependent (phrenic nerve stimulation may eventually allow independence from ventilator). 68.9.3 Incomplete spinal cord injuries Central cord syndrome General information Key concepts ● ● ● disproportionately greater motor deficit in the upper extremities than lower usually results from hyperextension injury in the presence of osteophytic spurs surgery is often employed for ongoing compression, usually on a non-emergency basis except for rare cases of progressive deterioration https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1133 Originally described by Schneider et al33 in 1954. Central cord syndrome (CCS) is the most common type of incomplete spinal cord injury syndrome. Usually seen following acute hyperextension injury in an older patient with pre-existing acquired stenosis as a result of bony hypertrophy (anterior spurs) and infolding of redundant ligamentum flavum (posteriorly), sometimes superimposed on congenital spinal stenosis. Translational movement of one vertebra on another may also contribute. A blow to the upper face or forehead is often disclosed on history, or is suggested on exam (e.g., lacerations or abrasions to face and/or forehead). This often occurs in relation to a motor vehicle accident or to a forward fall, often while intoxicated. Younger patients may also sustain CCS in sporting injuries; see burning hands syndrome (p. 1711). CCS may occur with or without cervical fracture or dislocation.34 CCS may be associated with acute traumatic cervical disc herniation. CCS may also occur in rheumatoid arthritis. Pathomechanics Traditional dogma was that the centermost region of the spinal cord is a vascular watershed zone which renders it more susceptible to injury from compression or edema, and that the lateral corticospinal tract (CST) was somatotopically organized such that cervical fibers are located more medially than the fibers serving the lower extremities. This anatomical model has been convincingly challenged by Levi and Schwab,35 who theorize that the proportionally greater effect on the upper extremities is due to the predominance of large-diameter motor axons subserving the upper extremities (especially the highly represented hands which is responsible for human manual dexterity), along with the fact that motor function of the lower extremities can be conveyed via other motor tracts including the rubrospinal and vestibulospinal tracts. Presentation The clinical syndrome is somewhat similar to that seen in syringomyelia33 1. motor: weakness of upper extremities with lesser effect on lower extremities 2. sensory: varying degrees of disturbance below level of lesion may occur 3. myelopathic findings: sphincter dysfunction (usually urinary retention) Hyperpathia to noxious and non-noxious stimuli is also common, especially in the proximal portions of the upper extremities, and is often delayed in onset and extremely distressing to the patient.36 Lhermitte’s sign (p. 1712) occurs in ≈ 7% of cases. Natural history There is often an initial phase of improvement (characteristically: LEs recover first, bladder function next, UE strength then returns with finger movements last; sensory recovery has no pattern) followed by a plateau phase and then late deterioration.37 90% of patients are able to walk with assistance within 5 days.38 Recovery is usually incomplete, and the amount of recovery is related to the severity of the injury and patient age.39 If CCS results from hematomyelia with cord destruction (instead of cord contusion), then there may be extension (upward or downward). Evaluation Findings: young patients tend to have disc protrusion, subluxation, dislocation or fractures.38 Older patients tend to have multi-segmental canal narrowing due to osteophytic bars, discs, and inbuckling of ligamentum flavum.38 C-spine X-rays: may demonstrate congenital narrowing of AP diameter of spinal canal, superimposed osteophytic spurs, traumatic fracture-dislocation. Occasionally, AP narrowing alone without spurs may be seen.34 Plain X-rays will fail to demonstrate canal narrowing due to thickening or inbuckling of ligamentum flavum, hypertrophy of facet joints, and poorly calcified spurs.34 Cervical CT scan: also helpful in diagnosing fractures and osteophytic spurs. Not as good as MRI for assessing status of discs, spinal cord, and nerves. MRI: discloses compromise of anterior spinal canal by discs or osteophytes (when combined with plain C-spine X-rays or CT, it increases the ability to differentiate osteophyte from traumatic disc herniation). Also good for evaluating ligamentum flavum. T2WI may show spinal cord edema acutely,40 and can detect hematomyelia. MRI is poor for identifying fractures. https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1134 Spine Trauma Treatment General information Key concepts ● ● there is no role for surgery without ongoing compression or instability timing (for patient with ongoing spinal cord compression) ○ emergency surgery: documented progressive deterioration should be decompressed ASAP ○ early surgery (≤ 24 hrs) when possible for spinal instability or patients with long tract findings (p. 1149) ○ patients that are improving should be followed and decompression can be done electively (usually within 2–3 weeks) without an arbitrary waiting period Practice guideline: Acute traumatic central cord injuries 68 Level III39,41 ● ICU management of patients with acute traumatic central cord syndrome (ATCCS), especially for those with severe neurologic deficits (because of possible cardiac, pulmonary & BP disturbances) ● medical management to include the following: cardiac, hemodynamic, and respiratory monitoring and maintainence of MAP 85–90 mm Hg (use BP augmentation if necessary) for the 1st week after injury to improve spinal cord perfusion ● early reduction/stabilization of fracture-dislocation injuries ● surgical decompression of the compressed spinal cord, particularly if the compression is focal and anterior. Unresolved: the role of surgery in ATCCS with long segment cord compression or with spinal stenosis without bony injury41 (see text for details) Indications & timing of surgery Surgical indications 1. continued compression of the spinal cord (e.g., by osteophytic spurs) that correlates with the level of deficit with any of the following: a) persistent significant motor deficit following a varying period of recovery (see below) b) deterioration of function c) continued significant dysesthetic pain 2. instability of the spine Timing of surgery Background: a perennial point of controversy. Early dogma was that early surgery for this condition is contraindicated because it worsened the deficit. In the absence of spinal instability, traditional management consisted of bed rest in a soft collar for ≈ 3–4 weeks, with consideration for surgery after this time, or else gradual mobilization in the same collar for an additional 6 weeks. However, the basis for this recommendation was at least in part derived from an early report of only 8 patients with CCS, 2 of which underwent surgery, with 1 being worse post-op (the operation consisted of laminectomy, opening the dura, sectioning the dentate ligament, and manipulation of the spinal cord in order to inspect the anterior spinal canal).33 ▶ Early surgery. Early (usually considered < 24 hrs after injury) decompressive surgery (without cord manipulation) appears to be safe42 in medically stable patients (see section 69.6 for discussion of timing). The strongest indications for early surgery for ATCCS are: ● the rare patient who is improving and then deteriorates.43 However, great restraint must be used in avoiding what would be an inappropriate operation in many patients44 ● additional presence of long tract findings: i.e., not a pure CCS, but a combination of other types of incomplete SCI ▶ “Delayed surgery.” Defined as surgery after 24-26 hours following SCI. For patients with ATCCS with significant persistent cord compression who consistently fail to progress after an initial period of improvement,40 surgery is indicated often within 2–3 weeks following the trauma without an arbitrary waiting period. Better results occur with decompression within the first few weeks or months rather than very late (e.g., ≥ 1–2 years).45 (p 1010) https://ebooksmedicine.net/neurosurgery-book | 14.02.23 - 13:47 Spine Injuries – General Information, Neurologic Assessment 1135 Some authorities contend that the worst time to operate on patients is starting 48 hours from the injury and lasting several days to a week due to swelling of the spinal cord which may render it fragile. Technical considerations of surgery The most rapid procedure to decompress the cord is often a multi-level laminectomy. This is frequently accompanied by dorsal migration of the spinal cord which may be seen on MRI.37 With myelopathy, fused patients fare better than those that are just decompressed without fusion. Fusion may be accomplished posteriorly (e.g., with lateral mass screws and rods) at the time of decompression, or anteriorly (e.g., multi-level discectomy, or corpectomy with strut graft and anterior cervical plating) at the same sitting as the laminectomy or staged at a later date. Prognosis In patients with cord contusion without hematomyelia, ≈ 50% will recover enough LE strength and sensation to ambulate independently, although typically with significant spasticity. Recovery of UE function is usually not as good, and fine motor control is usually poor. Bowel and bladder control often recover, but bladder spasticity is common. Elderly patients with this condition generally do not fare as well as younger patients, with or without surgical treatment (only 41% over age 50 become ambulatory, versus 97% for younger patients46). Anterior cord syndrome General information AKA anterior spinal artery syndrome. Cord infarction in the territory supplied by the anterior spinal artery. Some say this is more common than central cord syndrome. May result from occlusion of the anterior spinal artery, or from anterior cord compression, e.g., by dislocated bone fragment, or by traumatic herniated disc. Presentation 1. paraplegia, or (if higher than ≈ C7) quadriplegia 2. dissociated sensory loss below lesion: a) loss of pain and temperature sensation (spinothalamic tract lesion) b) preserved two-point discrimination, joint position sense, deep pressure sensation (posterior column function)47 Evaluation It is vital to differentiate a non-surgical condition (e.g., anterior spinal artery occlusion) from a surgical one (e.g., anterior bone fragment). This requires one or more of: myelography, CT, or MRI. Treatment Surgical intervention is indicated for patients with evidence of cord compression (e.g., by large central disc herniation) or for spinal instability (ligamentous or bony). Prognosis The worst prognosis of the incomplete injuries. Only ≈ 10–20% recover functional motor control. Sensation may return enough to help prevent injuries (burns, decubitus ulcers…). Brown-Séquard syndrome General information Spinal cord hemisection. First described in 1849 by Brown-Séquard.48 Etiologies Usually a result of penetrating trauma, it is seen in 2–4% of traumatic spinal cord injuries.49 Also may occur with radiation myelopathy, cord compression by spinal epidural hematoma, large cervical disc herniation50,51,52 (rare), spinal cord tumors, spinal AVMs, cervical spondylosis, and spinal cord herniation (p. 1404). https://ebooksmedicine.net/neurosurgery-book 68 | 14.02.23 - 13:47 1136 Spine Trauma Presentation Classical findings (rarely found in this pure form): 1. motor: ipsilateral weakness below lesion (due to lateral corticospinal tract dysfunction). Neuroanatomical correlate: motor fibers of the lateral corticospinal tract cross at the pyramidal decussation in the medulla 2. dissociated sensory loss a) contralateral loss of pain and temperature sensation inferior to lesion (lateral spinothalamic tract dysfunction) starting 1-2 levels below the lesion. Neuroanatomical correlate: pain & temperature fibers cross and ascend 1-2 levels in the dorsolateral fasciculus (zone of Lissauer) before entering the contralateral lateral spinothalamic tract b) ipsilateral loss of vibratory and joint position sense and touch and pressure (dorsal column dysfunction) starting at the level of the lesion. Neuroanatomical correlate: these fibers are transmitted by the dorsal columns of the spinal cord which ascend uncrossed until they decussate in the medial lemniscus in the medulla c) contralateral loss of crude touch due to disruption of the anterior spinothalamic tract. This may be partially mitigated to varying degrees by redundant fibers in the ipsilateral spinotectal tract Prognosis 68 This syndrome has the best prognosis of any of the incomplete spinal cord injuries. ≈ 90% of patients with this condition will regain the ability to ambulate independently as well as anal and urinary sphincter control. Posterior cord syndrome AKA contusio cervicalis posterior. Relatively rare. Produces pain and paresthesias (often with a burning quality) in the neck, upper arms, and torso. There may be mild paresis of the UEs. Long tract findings are minimal. References [1] White AA, Panjabi MM. The Problem of Clinical Instability in the Human Spine: A Systematic Approach. In: Clinical Biomechanics of the Spine. 2nd ed. Philadelphia: J.B. Lippincott; 1990:277–378 [2] Waters RL, Adkins RH, Yakura J, et al. Profiles of Spinal Cord Injury and Recovery After Gunshot Injury. Clin Orthop. 1991; 267:14–21 [3] Atkinson PP, Atkinson JLD. Spinal Shock. Mayo Clinic Proceedings. 1996; 71:384–389 [4] Chesnut RM, Narayan RK, Wilberger JE, et al. Emergency Management of Spinal Cord Injury. In: Neurotrauma. New York: McGraw-Hill; 1996:1121– 1138 [5] Hirsch SA, Hirsch PJ, Hiramoto H, et al. Whiplash Syndrome: Fact or Fiction? Orthop Clin North Am. 1988; 19:791–795 [6] Riley LH, Long D, Riley LHJr. The Science of Whiplash. Medicine. 1995; 74:298–299 [7] Spitzer WO, LeBlanc FE, Dupuis M, et al. Scientific Approach to the Assessment and Management of Activity-Related Spinal Disorders: A Monograph for Clinicians: Report of the Quebec Task Force on Spinal Disorders. Chapter 3: Diagnosis of the Problem (The Problem of Diagnosis). Spine. 1987; 12:S16– S21 [8] Spitzer WO, Skovron ML, Salmi LR, et al. Scientific Monograph of the Quebec Task Force on WhiplashAssociated Disorders: Redefining "Whiplash" and Its Management. Spine. 1995; 20:1S–73S [9] Radanov BP, Sturzenegger M, Di Stefano G. LongTerm Outcome After Whiplash Injury. Medicine. 1995; 74:281–297 [10] Hamilton MG, Myles ST. Pediatric Spinal Injury: Review of 61 Deaths. Journal of Neurosurgery. 1992; 77:705–708 [11] Hamilton MG, Myles ST. Pediatric Spinal Injury: Review of 174 Hospital Admissions. Journal of Neurosurgery. 1992; 77:700–704 [12] Mandabach M, Ruge JR, Hahn YS, et al. Pediatric axis fractures: early halo immobilization, management and outcome. Pediatric Neurosurgery. 1993; 19:225–232 [13] Garton HJL, Park P, Papadopoulos SM. Fracture dislocation of the neurocentral synchondroses of the axis. Case illustration. Journal of Neurosurgery. 2002; (Spine 3) 96 [14] Fassett DR, McCall T, Brockmeyer DL. Odontoid synchondrosis fractures in children. Neurosurg Focus. 2006; 20 [15] Rozzelle CJ, Aarabi B, Dhall SS, et al. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2013; 72 Suppl 2:205–226 [16] Suss RA, Zimmerman RD, Leeds NE. Pseudospread of the Atlas: False Sign of Jefferson Fracture in Young Children. AJR. 1983; 140:1079–1082 [17] Shaw M, Burnett H, Wilson A, et al. Pseudosubluxation of C2 on C3 in polytraumatized children– prevalence and significance. Clin Radiol. 1999; 54:377–380 [18] Bailey DK. The Normal Cervical Spine in Infants and Children. Radiology. 1952; 59:712–719 [19] Townsend EH, Rowe ML. Mobility of the Upper Cervical Spine in Health and Disease. Pediatrics. 1952; 10:567–574 [20] Jacobson G, Bleeker HH. Pseudosubluxation of the Axis in Children. Am J Roentgenol. 1959; 82:472– 481 [21] Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic? Radiology. 1977; 122:759–763 [22] Bailes JE, Hadley MN, Quigley MR, et al. Management of Athletic Injuries of the Cervical Spine and Spinal Cord. Neurosurgery. 1991; 29:491–497 [23] Torg JS, Corcoran TA, Thibault LF, et al. Cervical Cord Neuropraxia: Classification, Pathomechanics, Morbidity, and Management Guidelines. Journal of Neurosurgery. 1997; 87:843–850 [24] Maroon JC. "Burning Hands" in Football Spinal Cord Injuries. Journal of the American Medical Association. 1977; 238:2049–2051 https://ebooksmedicine.net/neurosurgery-book