Traumatic Spine and Spinal Cord Injuries

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Traumatic Spine and Spinal Cord Injuries

• Dafina M. Good, MD
• Emory University School of Medicine
• Childrens Healthcare of Atlanta
• Pediatric Emergency Medicine Fellow

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Objectives

• To review the epidemiology of Spinal Cord
  Injuries (SCI) in children
• To review the Anatomy of the spine and spinal
  cord
• To review pertinent history and physical exam
  findings involved in SCIs
• To review the radiologic evaluation of spinal
  trauma
• To review traumatic spine fractures
• To review some partial spinal cord syndromes

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Epidemiology of Spinal Trauma in Children

• Spinal injury is rare in children
• Higher mortality in children
• Pediatric vertebral injuries occur 60-80 of the
  time in the cervical region (30-40 of all
  vertebral injuries in adults)
• Overall incidence of spinal injury in children is
  1-2
• Almost 1500 children are admitted to US hospitals
  each year for treatment of SCIs
• Motor Vehicle Accidents are the leading cause of
  pediatric SCI (60 of cases)with falls and
  sports injuries (football and diving) thereafter
• MF ratio of 21
• Avg age is 14 to 15 yrs old
• 2006 study from the NTDB the KID found that
  almost 70 of children injured in MVAs from
  1997-2000 were not wearing a seatbelt and in 30
  of those cases alcohol or drugs were involved

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Cervical Spine Anatomy
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Spine Vertebrae Anatomy
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Spine Vertebrae Anatomy
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Cervical Spine Anatomy
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Cervical Spine Anatomy
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Atlas-Dens Relationship
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Anatomy of the Spinal Columns
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Pediatric vs. Adult Spine Anatomy..Not just
little adults!

• Children younger than 8yrs are more susceptible
  to C-spine injuries because
• Larger head to body proportion
• Higher fulcrum. point of maximal mobility
  (C2-3 at birth, C3-5 at 8-12yrs old to C5-6 at
  12yrs old and adults)
• Weaker cervical musculature
• Increased ligamentous laxity leading to greater
  mobility of the c-spine
• Immature joints and Ossification centers
• Horizontal facet joints that facilitate sliding
  of the upper C-spine
• More susceptible to subluxation and distraction
  injuries
• Spinal columns are more elastic than the spinal
  cord (tolerating more distraction before
  rupture. Thus leading to SCIWORA

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Key History and PE Components

• History
• Cause. MVA, Sports (Football/Diving), Falls
• Mechanism.. Hyperflexion (Clay shovelers or
  Teardrop Fxs), hyperextension (Hangmans Fx),
  Rotational (Jumped Facets), Compression or axial
  loading (Jefferson/Burst Fx)
• Symptoms.. Numbness, tingling, or weakness
  during any time since accident even if resolved
• Predisposing conditions.. 15 Downs Syndrome
  pts have atlantoaxial instability, Achondroplasia
  (Cervicomedullary Junction stenosis)
• Vital signs
• Hypotension, Bradycardia.. Can be signs of
  Neurogenic shock
• Physical Exam
• Testing for motor or sensory deficits and levels
  if present
• DTRs and rectal tone
• High index for Multisystem trauma (40 of cases
  have associated intrabdominal injuries)

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Radiologic Evaluation of Spine Injuries

• Are Xrays indicated?
• NEXUS Study Criteria (National Emergency
  X-Radiography Utilization Study)
• Based on 5 low-risk criteria that allows
  physicians to avoid Xray evaluation
• Must have absence of.. Midline cervical
  tenderness, evidence of intoxication, altered
  level of alertness, focal neurological deficit,
  and a distracting painful injury.
• Lateral, AP and Odontoid view
• 3 views picks up gt90 of all unstable C-spine
  injuries
• Lateral is the most important view. Lateral
  alone has a very high sensitivity
• Difficult to obtain odontoid views in pediatrics
• Swimmers view used as adjunct to Lateral if not
  able to visualize C7-T1 junction
• Flexion-Extension views
• Indicated if normal 3views of the c-spine but
  focal neck pain persists.. ie. Concerns for
  ligamentous injury
• Only in conscious patients who can limit their
  neck motion
• CT C-spine
• Excellent sensitivity for identifying fractures
  (Sensitivity of 97)
• Limited in showing ligamentous injury
• MRI
• Indicated in any patient with neurological
  deficits

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C-spine film evaluation

• Measurable Parameters of Normal Cervical Spine
  Radiographs
• Adequacy of C-spine views
• C1- top of T1
• 3 views vs. Single Lateral view
• Swischuk's Lines- 4 Lordotic curves aligned
• Predental space (5 mm or less)
• C2-C3 pseudosubluxation (4 to 5 mm or less)
• Retropharyngeal or Prevertebral space (1/2 to 2/3
  vertebral body)
• Intervertebral disk space symmetry
• If a C-spine fracture found.. Requires
  radiologic evaluation of entire spine.
• Approximately 10 of patients with a C-spine
  fracture have a second vertebral column fracture

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C-spine Lateral View
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C-spine AP View
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C-spine Odontoid View
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C-spine Odontoid View
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Swischuks Lines

• LINES OF LIFE There are 4 basic parallel lines
  to evaluate alignment that help determine c-spine
  injuries.
• Anterior vertebral body line
• Posterior vertebral bodyline
• Spinal Laminar line
• Posterior spinous process

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C-spine Films
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Predental Space
Space should be no more than 5mm
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Intervertebral Disk Spaces
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7yr old fell off her bunk bed 3 days ago and
still has a crook in her neck
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C1-C2 Rotary Subluxation
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Abnormal Odontoid View
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Abnormal Odontoid View
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Jefferson Fracture (C1 Burst Fracture)

• Axial loading or vertebral compression
• Displaced lateral masses of C1
• Predental space increased
• Moderately unstable

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Transverse Ligament Rupture


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Transverse Ligament Rupture
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Transverse Ligament Rupture
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Atlanto-occipital Dislocation


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Atlanto-Occipital Dislocation

• Widening of the atlanto-occipital joint gt5mm
• Prevertebral swelling
• Usually fatal
• Patients usually apneic at the scene
• 5X more common in children

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Odontoid View
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Type II Dens Fracture
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Hangmans Fracture
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Clay-Shovelers Fracture

• Spinous process avulsion fracture
• Very stable

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Flexion Teardrop Fracture

• Sudden hyperflexion with axial compression
• Involves disruption of all columns
• Usually presents with neurological impairment
• (Anterior cord syndrome)
• Highly unstable

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Bilateral Facet Dislocation

• Hyperflexion with Rotation (MVA/Diving)
• Disruption of all the spinal ligamentous columns
• Highly unstable
• Almost always quadriplegic (Poor prognosis)

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Chance Fracture

• AP Thoracic Spine

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Chance Fracture

• Hyperflexion injury
• Lap belt injury
• Transverse fractures through the VB
• 50 associated with intrabdominal
  
  organ injuries
• Posterior column disruption

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Spinal Cord Injury Without Radiographic
AbnormalitySCIWORA

• First described in 1982
• Defined as traumatic myelopathy in the absence of
  findings on plain radiographs, flexion-extension
  radiographs and cervical CT scan.
• Almost unique to pediatrics. Occurs most often
  in children younger than eight years of age
• Pediatric predominance likely related to the high
  elasticity of the spinal column in comparison to
  the spinal cord
• Usual mechanism is acceleration-deceleration or
  rotation injury
• Almost 20-50 of SCIs in children have no
  radiographic abnormalities
• Almost 30-50 of patients have delayed onset of
  neurologic deficits from 30mins-4 days
• If SCIWORA is suspected then an MRI should be
  done
• These patients require immobilization to prevent
  secondary insults to the spinal cord

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• Review of
• Traumatic Spinal Cord Syndromes

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Motor Innervation of the Nervous System
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Sensory Innervation of the Nervous System
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3 Main Spinal Cord Tracts

• Corticospinal tract carries motor fibers to the
  ipsilateral side of the body
• Posterior columns carry fine touch, vibration,
  proprioception, and pressure from the ipsilateral
  side.
• Spinothalamic tract carries pain and temperature
  fibers from the contralateral side of the body.

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Partial Cord Syndromes
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Central Cord Syndrome

• Most common of the partial cord syndromes
• Hyperextension injury in athletes
• Ligamentum flavum buckles and increases pressure
  on the cord
• Bilateral motor paresis greater in the upper than
  lower extremities
• Shawl distribution pain and temperature loss
• Sparing of light touch and proprioception
• Good prognosis

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3 Main Spinal Cord Tracts

• Corticospinal tract carries motor fibers to the
  ipsilateral side of the body
• Posterior columns carry fine touch, vibration,
  proprioception, and pressure from the ipsilateral
  side.
• Spinothalamic tract carries pain and temperature
  fibers from the contralateral side of the body.

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Anterior Cord Syndrome

• Crush Injury or compression from a hematoma
• Compression of the Anterior Spinal artery
• Paraplegia below the lesion
• Pain and temperature loss below the lesion
• Sparing of dorsal column sensation

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Brown Sequard Syndrome

• Hemisection of the spinal cord
• Usually from penetrating trauma
• Ipsilateral plegia below the lesion
• Ipsilateral proprioception and light touch loss
  
  below the lesion
• Contralateral pain and temperature loss
  
  below the lesion
• Rare injury