PRESENTER – Dr.

HERSHDEEP SINGH
 None
 To get acquainted with

- The basic epidemiology of spine trauma.

- Various classificatory systems present for spine trauma.

- Typical presentation of cervical, thoracolumbar and sacral

spine trauma.
 Smaller bodies
 Less weight
bearing
 Extensive joint
surface
 Greater ROM
 Lesser ROM
 Ribs attachment
 Bear weight
 Thicker bodies
 Traumatic injuries result in great burden on health care system
particularly in LAMICs

 Indian society is leaning towards westernization over the past

two decades resulting in various forms of risk taking behavior.

 Overspeeding, avoiding safety measures, DUIs (in adolescents as

well as adults)

 In India - 375 deaths and more than 1200 injuries per day due to
road accidents in the country. (NCRB, 2011)

 large number - spine trauma and traumatic spinal cord injury.

 Incidence in developing countries- 25.5/million/year

 Male predominance(82.8%); female in elderly

 Mean age – 32.4 years

 MVC 41.4% and falls 34.9%

 Complete and incomplete SCI; 56.5 and 43.0%, respectively

 Paraplegia and tetraplegia; 58.6 and 40.7%, respectively

 Most common site- Thoracolumbar junction (T10-L2)

 Most common complication- Development of pressure

ulcers. (Movaghar et al 2013)
 Flexion

 Extension

 Rotation

 Lateral bending

 Distraction (stretching)

 Compression (axial loading)

(Torlincasi, 2019)
 Location
- Cervical spine injury
- Thoracic spine injury
- Thoracolumbar junction injury
- Lumbar spine injury
- Sacral spine injury

 Morphology
- Configuration of fracture line
- Extent of tissue involvement
- Presence of displacement
 Traneylis’s classification of Occipitoatlantal

dislocation

 Anderson and montesno classification of Occiput

condyle fracture

 Landells and Van Peteghem classification system99 for

Jefferson (atlas) fractures

 Bohler’s
 Holdsworth

 Allen classification of CSI

 The AO SLIC (Subaxial injury classification and

severity score system)

 In 1986, Traynelis and associates39 proposed a classification
system with three types of OAD

 based on the displacement of the occiput over the atlas in

radiographs.

 Type I describes an anterior displacement of the occiput with

respect to the atlas.

 Type II is a distraction injury with vertical displacement.

 Type III involves posterior displacement of the occiput.

 Lateral, rotational, and multidirectional dislocations cannot be

classified using this system and could be considered as “other
types”
 Anderson and Montesano classified OCFs84 into three

types

 Type I is a comminuted fracture of the condyle.

 Type II is an extension of a linear skull base fracture

involving the occipital condyle.

 Type III is an avulsion of a fragment of the condyle.

 Useful for determining treatment alternatives.

 Types I and II are considered stable fractures,

and patients require external immobilization of
the head and cervical region alone.

 Type III fractures are considered unstable, with

the patient potentially requiring internal fixation
of the injury because of its ligamentous nature.
 In 1988, Landells and Van Peteghem classified C1 fractures
into three types
 Type I (anterior or posterior arch fracture) is confined to a
single arch and does not cross the equator of the atlas;
however, each arch can be involved.
 Type II (burst fracture) involves both arches and crosses
the equator of the atlas; two or more fragments may be
present.
 Type III (lateral mass fracture) has a fracture line
extending from the lateral mass into one arch only
 Each lower cervical injury is divided into 6 categories of injury

 Based on the attitude of the cervical spine at the time of injury and the dominant
force vectors

- Compressive flexion

- Vertical compression

- Distractive flexion

- Compressive extension

- Distractive extension

- Lateral flexion.

 Each category, ranging from mild to severe, related at the same time with
neurological impairment.
 Based on 3 components of injury

- Mechanism/Morphology

- Integrity of the posterior ligamentous complex

- Neurological status of the patients

 Score of 4 or less- managed conservatively

 Score of 6 or more-surgically operated

 Score of 5 may be managed either with surgery or non

operatively at the surgeon’s discretion
(Dvorak et al, 2007)
 Fracture morphology
- Type A- Compression lesions to the anterior column
- Type B- Distraction lesions of either the anterior or the
posterior column
- Type C- Translationally unstable lesions
- Type F- Facet injuries
 Neurologic status 5 categories –
- Transient neurologic injury (N1)
- radicular symptoms or deficits (N2)
- incomplete spinal cord injury (SCI) or any kind of cauda equina injury
(N3)
- complete SCI (N4) and
- unknown neurologic status (NX)
 Additional modifiers- Disorders which affect treatment strategy, such as
osteoporosis or ankylosing diseases.
 Bohler’s classification

 Holdsworth’s classification

 Denis’s classifiction

 The Thoracolumbar injury classification and severity score (TLICS)

 AO Spine classification of TLSI

 Mcaafee’s classification

 Load share classification

 Based on both anatomic appearance and mechanisms
of injury to include

- Compression fractures

- Flexion-distraction injuries

- Extension fractures

- Shear fractures

- Rotational injuries
 Introduced the columnar concept of stability.

 Insisted that the integrity of the posterior column is

necessary for stability of the thoracolumbar spine.

 Visualized the spine as two columns: the anterior

column (vertebral body + intervertebral disk) and the
posterior (facet joints + posterior ligamentous
complex.
 Categories

- Anterior compression fractures

- Fracture-dislocation

- Rotation fracture-dislocation

- Extension injuries

- Burst fractures

- Shear injuries
 Came in the era of computed tomography (CT)

 CT imaging allowed visualization of finer details of spinal

injuries, including osseous anatomy surrounding the spinal canal.

 Denis gave three-column concept.

 Anterior column as the anterior longitudinal ligament to the

anterior two-thirds of the vertebral body

 Middle column as the posterior one-third of the vertebral body

including the anulus fibrosus and posterior longitudinal ligament

 Posterior column, which includes all structures posterior to the

posterior longitudinal ligament.
 Categories

 Compression fractures

 Burst fractures

 Fracture-dislocations

 Seatbelt injuries.

 Denis also named

- isolated mechanical instability “first degree” injuries

- neurologic deterioration as “second degree” injuries

- combined mechanical and neurologic deterioration as “third

degree” injuries.
 Created by “The Spine Trauma Study Group (STSG)”

 Based on a survey given to the Spine Trauma Study Group

(worldwide experts in the field of spinal trauma)

 The goal of the survey

- To identify similarities in treatment algorithms for common

thoracolumbar injuries

- To identify characteristics of injury that played a key role

in the decision-making process.
 Based on three major categories

- the morphology of the injury

- the integrity of the posterior ligamentous

complex

- the neurologic status of the patient.

 Higher total points indicate a more severe injury

 Fracture morphology

- Type A- Compression injuries.

- Type B- Failure of the posterior or anterior tension band.

- Type C- Failure of all elements leading to dislocation or

displacement.

 Neurologic status 5 categories ( same as CSI)

 Additional modifiers
 Based on morphology

Type A- lower sacrococcygeal injuries; no impact

on posterior pelvic or spino pelvic instability

Type B- posterior pelvic injuries; minimal to no

impact on spinopelvic stability

Type C- spinopelvic injuries; spino pelvic instability

 Wedge compression fractures

 Stable burst fractures

 Unstable burst fractures

 Chance fractures

 Flexion distraction injuries

 Translational injuries
 Aka McCormack-Gaines load-sharing classification / Load sharing
classification of burst fractures.
 Given by McCormack et al, 1994
 Grades:
- the amount of damaged vertebral body
- the spread of the fragments in the fracture site, and
- the amount of corrected traumatic kyphosis.
 can be used preoperatively to:
- predict screw breakage when short segment, posteriorly placed
pedicle screw implants are being used
- describe any spinal injury for retrospective studies, or
- select spinal fractures for anterior reconstruction with strut
graft, short-segment-type reconstruction.(McCormack, 1994)
 6 points or less (fractures with mild comminution)

- Can be successfully repaired from the posterior approach with

pedicle screw implants.

 7 points or more (Severely comminuted fractures)

- Must be repaired by an anterior approach with vertebrectomy and

strut grafting.
ANALYSING THE CLASSIFICATORY SYSTEMS
 Does not allow to make a comparison, in terms of neurological outcome,

between different categories

 fails to explain clearly some important force vectors, such as rotation

and their implication in spine stability.

 Neurological status is not included as a criteria of this structural and

mechanistic classification.

 Individuals with SCI without radiological abnormalities (SCIWORA) are

underrepresented and may lead to mistakes in terms of management and

predicting clinical outcome

 Bohler’s classification
- Did not attempt to define instability patterns based on the
anatomical appearance of the injury.
 Holdsworth’s Classification
- Oversimplified the biomechanics of injury in thoracolumbar
fractures. For example, unstable burst fractures based on
their natural history were falsely categorized as “stable”
when, in fact, many of these fractures progressed to
kyphosis and increased neurological deficits.
 Remains the most popular to date, mostly because of its

simplicity.

 Oversimplification that instability exists if two of three

columns are disrupted loss of Denis’ original emphasis on

the distinction of mechanical and neurologic instability.

 Does not provide prognostic information or consider the
patient’s neurologic status, and therefore it cannot
adequately guide surgical intervention

 No clear useful algorithm for treating unstable injuries.

 Since it uses the terms stable and unstable. In many cases,

however, there is no good correlation with the necessity
for surgery. (Kelly et al 1968, Agus et al 2004)

 Lack of clarity on how ligamentous injuries (which may

lead to occult, progressive instability) can be identified.
 Pros:

- Highly detailed subclassifications, the AO system has

shown limited inter-observer variability.

 Cons:

- Difficult to use.

- Does not incorporate the patient’s neurologic status.

 Morphology is better characterized by CT scan reconstruction in sagittal,
axial, and coronal plane

 Extra information can be obtained with the use of MRI

 Distraction and rotational injuries will, by definition, have an associated

PLC injury, with exception of pure chance fractures and some extension-
distraction injuries. Therefore, patients with distraction and rotational
injuries receive 3 (rotation) or 4 (distraction) points for morphology as
well as 3 points for PLC disruption, being treated surgically regarding of
the neurological status.

 Unlike the AO system, the TLICS allows for a definition of stable and
unstable burst fractures, based on integrity of the PLC.
 Assessment of the PLC status in burst fractures can be
made using MRI in the region of PLC elements or indirect
signs, such as diastasis of the facet joints.

 Surgical treatment is generally recommended for unstable

injuries, while stable burst fractures may be treated
conservatively.

 In burst fractures without neurological deficits, decrease

in vertebral body height, local kyphosis, or canal
compromise should not be considered independently in the
decision-making for surgery.
 Does not include subjective criteria that may be crucial in the decision-
making process such as

- Medical co-morbidities

- Traumatic injuries other than those involving the spine (e.g., multiple
limb fractures, closed head injury, internal organ injuries)

- Abrasions over potential operative sites, or excessive kyphosis.

- Other preexisting osseous disorders, such as ankylosing spondylitis,

diffuse idiopathic skeletal hyperostosis, or osteoporosis

 Designed as a guideline for surgeons and nonsurgeons to help determine

possible treatment options incorporation of these factors is critical.
 Among all, commonly used classification systems in routine

clinical practice:

- The Denis/McAfee classification

- AO classification

- The TLICS classification

 Inter-observer reliability of the AO classification is low and when

the injury is classified into subgroups, the inter-observer

reliability decreases further. (Blauth et al, 1999)

 Denis classification system shows higher inter-

observer reliability than the AO classification

system. (Oner et al,2002; Wood et al,2005)

 Lenarz et al, concluded that the TLICS is an

acceptably reliable system when compared with

the Denis and AO systems. (Lenarz et al,2009)

 Posterior neck pain on palpation of spinous

processes

 Limited range of motion associated with pain

 Weakness, numbness, or paresthesias along

affected nerve roots

 Spinal shock
 Flaccidity
 Areflexia
 Loss of anal sphincter tone
 Fecal incontinence
 Priapism
 Loss of bulbocavernosus reflex
 Neurogenic shock
 Hypotension
 Paradoxical bradycardia
 Flushed, dry, and warm peripheral skin
 Autonomic dysfunction
 Ileus
 Urinary retention
 Poikilothermia
 Craniocervical dissociation
 Atlantoaxial rotator subluxation; Transverse
ligament injury
 Odontoid & Hangman’s fracture
 Jeffersons fracture
 Clinical presentation
 Most common cause - High-speed motor vehicle accidents and
striking of pedestrians by motor vehicles.
 Brainstem or upper cervical spinal cord injury – immediate death
 Patients may be neurologically intact or have dysfunction of the
brainstem, cranial nerves, spinal cord, or cervical nerve roots.
 may have normal results on motor examination, or they may
display deficits, including vegetative posturing responses,
cruciate paralysis, or quadriparesis.
 At the level of C1, the normal spinal canal is capacious.
 Cruciate paralysis (Bell)- weakness in the hands and arms with
relative sparing of leg strength.
 Weakness often recovers, with improvement seen first proximally
and then distally in the hands.
(Youman’s Neurological surgery, 6th edition)
 Clinical presentation
 The “cock-robin” position of the neck.
- The patient is seen with the head tilted
to one side and rotated to the
contralateral side with slight flexion of
the neck.
- The patient cannot usually correct the
deformity beyond the neutral position
- attempts to reduce the deformity by
the examiner cause cervical pain.
 Compression of the greater occipital nerve or the C2 nerve root-
Occipital pain

 stretching or kinking of the vertebral arteries- Posterior fossa

symptoms (vertigo, nausea, tinnitus, visual disturbance)

 Differentiation of atlantoaxial subluxation from benign torticollis

is based on the side of sternocleidomastoid spasm.

- In torticollis, it occurs on the contralateral side of the head

rotation because contraction of the muscle leads to the neck
deformity.

- In rotatory subluxation, the muscle contracts in an attempt to

reduce the deformity.
 Spinal shock

 Concussive injury of the spinal cord

 Manifests as:

- distal areflexia of a transient nature (lasting a few hours to weeks)

- Initially, the patient experiences a flaccid quadriplegia along with

areflexia.

- Segmental reflexes start to return usually within 24 hours as

spinal shock starts to resolve.

- At that point, flaccid quadriplegia changes to spastic paralysis.

 Eventually, total resolution can be expected.

 Neurogenic shock

 Spinal shock that causes vasomotor instability because of loss of

sympathetic tone.

 Patients are hypotensive but have paradoxical bradycardia.

 Flushed, dry, and warm peripheral skin, (in contrast to findings with
hypovolemic or cardiogenic shock) may be present.

 Other signs of autonomic dysfunction include ileus, urinary retention,

and poikilothermia.

 Loss of anal sphincter tone with fecal incontinence and priapism

suggest spinal shock.

 Return of bulbocavernosus reflex heralds resolution of spinal shock.

 Complete and incomplete cord syndromes
Complete syndrome
- Cervical tetraplegia
- Thoracic and lumbar paraplegia
Incomplete syndromes
- Anterior cord
- Central cord
- Brown-Sequard
- Posterior cord
- Conus medullaris
- No motor or sensory function more than three

segments below the neurological level of injury

- There is absence of sacral sparing

 Affects the anterior 2/3 of cord

 Preserves the posterior column:

proprioception, vibratory sensation

 May be due to persistent

retropulsed bone or disc material/
mechanical insult

 Vascular component

 Loss of all motor and sensory below

injured level

 Deep pressure sensation only

 Poor prognosis for motor recovery

 Older patients with
preexisting spondylosis

 MOI: Hyperextension injury:

fall, whiplash

 Spinal cord pinched by

osteophytes anteriorly and
the underlying hypertrophic
ligamentum flavum
posteriorly; leads to
significant injury to the
“central portion” of the cord
 Best prognosis among common patterns Upper

extremity > lower extremity involvement

 Distal > proximal

 Earliest and greatest recovery in legs followed by

bladder

 Hand dexterity often slow to return, full recovery

variable
 Results from functional
hemisection of cord, projectile or
penetrating wound

 Loss of ipsilateral motor

 Loss of contralateral pain,

temperature, and light touch
sensation

 75% regain independent ambulation

 80% recover bowel and bladder

function
 Rare

 Loss of proprioception

 Maintain ambulation but

rely on visual input

 Direct injury to conus region (L1-L2)
 Presents as mixed lesion of cord and nerve root
damage
 Bowel, bladder, and sexual dysfunction
 Injury to CM can disrupt the bulbocavernosus
reflex arc
 Therefore, the absence of a bulbocavernosus
reflex unreliable indicator of spinal shock in this
clinical setting
 Lower motor neuron
lesion (not cord)
 Sacral segments more
affected than lumbar
 Saddle anesthesia
with incontinence
 Lumbar sparing
 Acute Torticollis
 Cauda Equina and Conus Medullaris Syndromes
 Cervical Strain
 Hanging Injuries and Strangulation
 Neck Trauma
 Septic Shock
 Spinal Cord Infections
 Spinal Cord Injuries
 Spinal Cord Neoplasms
 Thoracic Outlet Syndrome Imaging
 Vertebral Artery Dissection
 C1-C4 injury
 Quadriparesis
- Absent limb function
- Ventilator
dependence
- C4 level may be
ventilator
independent
 C5 – C8 injury
 Tetraplegia, Impaired:
- C5- deltoid , biceps
- C6- biceps, wrist
extension
- C7- wrist extension,
triceps
- C8- functional grasp
 Severe pain

 Deformity

 neurologic deficits related to compression

 Can produce a mixture of cord and root syndromes caused by lesions of

the conus medullaris and lumbar nerve roots.

 Lower lumbar fractures may cause solitary or multiple root deficits.

 However, massive disk herniations, fracture-dislocations, and burst

fractures in the lumbar region can cause a cauda equina syndrome with
variable paraparesis, asymmetrical saddle anesthesia, radiating pain, and
sphincter disturbances.
 Usually is limited by severe pain.

 Deviation of normal spine curves

 Muscle spasm from pain - flattens the spine

 kyphotic or scoliotic deformity may be present

 Tenderness

 Fractured or displaced spinous processes.

 The ASIA impairment scale, consists of five degrees of impairment, as
follows:
 A - No motor or sensory function is preserved below the neurologic level
of injury extending through the sacral segments S4-5
 B - Sensory function, but not motor function, is preserved below the
neurologic level of injury and extends through the sacral segments S4-5
 C - Motor function is preserved below the neurologic level of injury, and
most of the key muscles below the neurologic level have a muscle grade
of less than 3
 D - Motor function is preserved below the neurologic level of injury, and
most of the key muscles below the neurologic level of injury have a
muscle grade of 3 or higher
 E - Normal motor and sensory function are preserved
 In addition, a detailed neurologic evaluation should include the
following:
 Evaluation of sensory level
 Assessment of posterior column function
 Testing for normal and abnormal reflexes
 Examination of rectal tone and perianal sensation
 Beevor sign - consists of a cephalic movement of the
umbilicus when the patient is asked to elevate his or
her head in the supine position.
- denotes paralysis of the lower abdominal muscles
 Spinal shock can last 24-48 hours, suppressing all
reflex activity below the level of the lesion.
 Return of reflex activity (bulbocavernosus and anal
reflexes) in the absence of any return of sensation or
motor function generally is a poor prognostic
indicator.
 Thoracic spine injury
 Paraplegia
 Better respiratory and
trunk control with
injury at more caudal
level
 Thoracolumbar most
common
 Lumbar (L2-S1)

 Paraplegia; impaired

- L2- hip flexion

- L3,L4- knee extension

- L4- foot dorsiflexion

- L5- EHL

- S1- Gastrocsoleus
 Typically occur as injuries to the L5 or S1 nerve
roots.
 Sacral fractures frequently accompany pelvic ring
fractures
 may have S2-S5 sacral nerve root injuries.
 Lower sacral nerve root injuries may lead to bowel
and bladder incontinence and sexual dysfunction.
 Perineal numbness and decreased rectal tone in the
acute period can be seen on careful examination.
 Complete damage to the sacral portion of the cord-

loss of control of bowel and bladder function and

sacral motor paralysis of the lower extremities

 Preservation of some movement of the hips and knees

 Preserved knee jerks and sensation in the lumbar

dermatomes