Fundamentals of - Spinal Injury & Management, and Spinal Surgery: at - Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladeh

Fundamentals of Spinal Injury & Management -
CME ON-
& Management
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Prepared ByDr. Md. Nazrul Islam-MBBS, M.sc. (B.Eng).
Supervised By-
FROM-
Department of Orthopedics & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka -1207,
Section1 Section2 Section3 Section4
Section5
Section6 Section7
Introductions of Spine Spinal Injury (SI) Patho-physiology of Spinal Injury Fundamentals of Assessment & Diagnosis- Spinal Injury Patients Management of Spinal Injury Patients. Rehabilitation of SI Patients Conclusions
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&
Introductions Human of Spine

The human spine is a dynamic and complex structure, which entertains a symbiotic relationship between various muscular, ligamentous, vascular, and neural tissues. Injuries of the spine may affect an individual's form and function, and in some cases may lead to severe disability and death. Spinal injury (either bony or soft tissue) management pre-hospital/ hospital are equally very important for proper 4 treatment/ successful return to regular
Section- 1
Section- 1 Introductions of Spine
Concise History of Spinal Disorders Paleopathological investigators have
found Clear evidence of spinal disorders in prehistoric times. At the end of antiquity ( 7th century A.D.), Paulus of Aegina (625690 A.D.) performed the first successful laminectomies. At the beginning of the 21st century, spinal surgery has become more evidence based, but it is still technology driven in many areas. 5
Section- 1
Functions of Human Spine means of The spine provides a

the upper and lower body via the sacrum which connects the spine to the pelvis. The spine has many functions in providing humans with the ability to lead the lives they do o Strength and Support Movement Protection of Nerves 6 Blood Supply
connecting Introductions of Spine
Section- 1
Introductions of Spine Spine consists of alternating Bony vertebrae Fibrocartilaginous disc Supported by musculature. Motion segment Two adjacent vertebrae with intervening disc.
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Anatomy of Spine:
The Spine is an intricate structure of bones, ligaments, muscles, nerves, and tendons. Its anatomy can be broadly divided into
Hard Bony Part The backbone, or spine, is made up of 31 bony segments called vertebrae: o 8 cervical (neck) vertebrae o 12 thoracic (middle back) vertebrae o 5 lumbar (lower back) vertebrae* o 5 sacral (lowest area of the back) vertebrae 8 o 1 coccygeal (coccyx, or tailbone)
Anatomy of Spine:
Soft Tissue Part
Spinal Cord Inter vertebral disc Muscles Tendon ,Ligaments Nerve Vessels 9
Anatomy of Spine:
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Anatomy of Spine:
Spinal Muscles -
Muscles around the spine play a key role in the health of the back. It support the trunk and hold the body upright. They also allows the trunk to move, twist and bend in multiple directions. Three types of back muscles that help spinal function are the: Extensor muscles- They include the large muscles in the lower back (erector spinae), which help hold up the spine, and gluteal muscles.
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Anatomy of Spine:
Spinal Muscles -
Flexor muscles- Attached to

the front of the spine, these muscles include the abdominal muscles. They allow us to flex, bend forward, lift and arch the lower back. Oblique muscles- These are attached to the sides of the spine. They help us rotate the 12 spine and maintain proper
Anatomy of Spine:
Spinal Ligaments -
Normal Anatomy and Composition Ligaments surrounding the spine provide intrinsic stability to the spine and limit motion in all planes. The spinal ligament complex includes: Interspinous Ligaments Supraspinous Ligaments Intertransverse Ligaments Yellow Ligaments (Ligament 13 Flavum)
Anatomy of Spine:
Neurovascular Components-
Blood supply
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Anatomy of Spine:
Neurovascular ComponentsVeins Supplying Spinal Column-
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Anatomy of Spine:
Anatomy of Spine: Spine & Nervous system
Neurovascular Components-
At the level of each spinal bone exits a spinal nerve. Each spinal nerve controls a variety of body functions. Functionally these nerve functions are very specific. Anatomically these nerves are closely attached to vertebral 16 body
Section- 1
Introductions of Spine
Age Related Change & Biomechanics of Spine -
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Age-Related Changes of the SpineThe spinal column degenerates far earlier than other musculoskeletal tissues Age-related changes of the spine are not synonymous with painful alterations Time course and probability of early disc degeneration are largely determined by genetic disposition The intervertebral disc is the largest avascularstructureof the human body resulting in large diffusion distances to allow for disc nutrition Compromised disc nutrition is a key factor for disc degeneration Changes in the matrix components of the 18 intervertebraldisc, especially the
Core Messages
Age-Related Changes of the Spine -
Orientation and misalignment of the facet joints correlate with development of early Age-Related osteoarthritis of the joint Changes of the Spine Changes in bone architecture of the vertebral bodies and formation of osteophytes alter mechanical properties of the spinal column Changes in matrix molecules and fiber orientation in ligaments alter behavior of the ligaments Age-related changes of the three joint 19
Age-Related Changes of the Spine At the cellular level:
Core Messages Age-Related Changes of the Spine -
Cellular senescence, leading to a
decreasing ability of somatic cells to replicate, repair, and maintain tissue Apoptosis (programmed cell death), leading to decreased cell numbers in the affected tissue Accumulation of post-translational modifications of matrix proteins, leading to altered properties of the extracellular matrix Increasing generation of oxidative stress due to generation of reactive oxygen species (ROS), leading to cell damage Genetic predisposition, leading to 20 premature aging or phenotypic changes in
Age-Related Changes of the Spine At the systemic level:
Declining levels of trophic hormones,
Core Messages
leading to altered tissue environment and response of tissue to use and injury General age-related changes, such as a decrease in reaction time, proprioception, vision, hearing, pulmonary and cardiovascular function, leading to decreased mobility and therefore affecting the musculoskeletal system Socioeconomic and psychosocial factors also contribute, mainly by 21 influencing the individual variation
Age-Related Changes of the Spine Grade I: Normal juvenile disc
Grade II: Normal adult disc Grade III: Early stage
Grade IV: Advanced stage Grade V: End stage
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Biomechanics of the Spine -
Stability of Spine-
Biomechanics of Spine -
Anterior column = anterior 2/3 of the vertebral body, disc, and annulus, and the anterior longitudinal ligament) Middle column = posterior 1/3 of the vertebral body, disc, annulus, and the posterior longitudinal ligament Posterior column = pedicles, laminae, facets, capsule, and the interspinous and supraspinous ligament. Spinal injury is said to be stable if only one of the columns is involved. Damage to two or more columns or risking neurological injury (i.e. damage to the middle5 23 column) - unstable.
Section- 1
Spine Unit -
Introductions of Spine
The smallest anatomical unit of the spine which exhibits the basic functional characteristics of the entire spine is called the motion segment or functional spine unit
24 Schematic representation of a functional spinal unit (motion segment) in a the cervical and b lumbar spine.
Core Section- 1 Messages Introductions of Spine
The trabecular bone bears the
majority of the vertical compressive loads The vertebral endplate plays an important role in mechanical load transfer and the transport of nutrients Axial disc loads are borne by hydrostatic pressurization of the nucleus pulposus, resisted by circumferential stresses in the anulusfibrosus 25 proximately 1020% of the total
Combined axial compression, flexion and

lateralbending have been shown to cause disc prolapse The facet joints guide and limit intersegmental motion The ligaments surrounding the spine guide segmental motion and contribute to the intrinsic stability of the spine by limiting excessive motion The spatial distribution of muscles determines their function. Changes to segmental laxity (neutral zone) are 26 associated with trauma and degeneration.
Section- 2
Spinal Injury (SI)
Spinal Injury (SI)

Spinal injury may be defined as-Injury to the Spinal column (Bony Column)/ Spinal Cord, or both of them. Spinal injury can be divided into Spinal Column(Bony)Injury. Spinal Cord injury. 27 Combined (Both Column
Section2
Spinal Column Injury

Bony spinal injuries may or may not be
Spinal Injury (SI)
associated with spinal cord injury These bony injuries include: Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae Other injuries may include: Sprains- over-stretching or tearing of ligaments 28 Strains- over-stretching or tearing of
Section2
Spinal Injury (SI)
Spinal Cord Injury

Spinal cord injury results from cutting, compression, or stretching of the spinal cord. Causing loss of distal function, sensation, or motion Caused by: Unstable or sharp bony fragments pushing on the cord, or Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia
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Section2
Spinal Injury (SI)
Causes of Spinal InjuryCommon causes of spinal injury

The
most common causes of spinal injuries are: Motor vehicle accidents Acts of violence Falls - Spinal injury after age 65 is most often caused by a fall. Sports and recreation injuries. Diseases- Cancer, arthritis, osteoporosis and cause spinal injuries. inflammation of the spinal cord also can
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Section2
Spinal Injury (SI)
Other causes of SI include the following:

Vascular disorders Tumors Infectious conditions Spondylosis Iatrogenic injuries, especially after spinal injections and epidural catheter placement. Vertebral fractures secondary to osteoporosis Developmental disorders. 31
Section2
Spinal Injury (SI)
Incomplete injury: Some motor or sensory functions is spared distal to the cord injury. Voluntary sphincter contraction, toe flexor contraction present. Prognosis-Good Complete injury: Total motor & sensory loss distal to the injury after Spinal shock (usually lasts for 24-48 hrs) is over. When the bulbo-cavernosus reflex is positive & no sacral sensation or 32 motor function has returned, paralysis
Section2
Denis Classification
Denis defined four types of spinal fractures:
Spinal Injury (SI)
(Denis divided the spine into three columns:
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Section2
Spinal Injury (SI)
Types of Spinal InjuryCompression fracture Flexion distraction Burst fracture Chance fracture Translation injury
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Section2
Level of Spinal Injury Level of spinal injury

55 % Cervical 15 % Thoracic 15 %Thoracolumbar
Spinal Injury (SI)
15 % Lumbosacral area
Approximately 10% of pts w / C
spine fracture have a second noncontiguous vertebral column fracture Five percent of brain-injured pts have associated spinal injury, 35 While 25% of spine injury patients
Section2
Spinal Injury (SI)
Patterns Of Multiple Spinal Injury :

Denis Classification
Pattern: A. Primary lesion occur between C5 & C7 with secondary injuries at T12 or the lumber spine. Pattern : B. Primary injury at T2-T4 with secondary injury in cervical spine. Pattern : C. Primary injury occur between T12 & L2 with secondary injuries from L4 -L5.
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Section2
Spinal Injury (SI)
Spinal Injury: Predisposing factors

AnkylosingSpondylitis Degenerative Disease Of
Spine Spinal Canal Stenosis Down's Syndrome Klippel- feil Syndrome Arnold- chiari Malformation Metastatic CA Osteomyelitis 37 Rheumatoid Arthritis
Section2
Epidemiology
Mean age 33 yrs 75% males 50% of SCIs are complete 50-60% of SCIs are cervical Immediate mortality for complete cervical SCI ~ 50%
Occurs primarily in young males (> 75% of cases) Half of these injuries result from MVAs 2/3 of patients are < 30 years old Other sources of SCI: Falls, sporting and industrial accidents, gunshot wounds. Most common vertebrae involved are C5, 38 9 C6, C7, T12, and L1 because they have the greatest ROM.
Spinal Injury (SI)
Risk factors:
Section2
Spinal Injury (SI)
Epidemiology Incidence

18 - 35 years Male - 3:1 RTA 51% - cars Domestic 16% Industrial 11% Sports 16% - diving incidents Self harm 5%
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Patho-physiology of Spinal Injury Section- 3
Spinal injury (SI) is an insult to the spine resulting in a change, either temporary or permanent, in its bone structure or soft tissue (Spinal cord, disc, nerves, ligaments or muscles) and/ or motor, sensory, or autonomic function.
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Section- 3
Patho-physiology Of Spinal Injury -
Mechanism of Spinal InjuryPrimary injury

Primary mechanism of cord injury can be due to four kinds of mechanical forces. a. Impact with persisting compression e. g. fractures, dislocations, and disc herniations. b. Impact with no persisting compression e. g. hyperextersion injuries. c. Distraction e. g. hyperflexion injuries. d. Laceration/ Transection: 41 8
Most likely to occur at sites of maximum mobility Adults C6 Children <8 yrs old C2.
Section- 3
Mechanism of Spinal InjuryPrimary injury
25% of spinal cord injuries occur after primary injury. Primary injury results from focal injuries (e.g. avulsion, contusion, laceration and intra-parenchymal hemorrhage) and diffuse lesions (e.g. concussive and diffuse axonal injury). Further mechanical disruption can result from external compression or angulation and ischemic damage from occlusion of 42 arterial supply.
Section- 3
Patho-physiology Of Spinal Injury Results from:
Cellular hypoxia Oligaemia
Mechanism of Spinal InjurySecondary Injury
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Section- 3

Secondary injury mechanisms that may be involved are: a. Systemic shock: Profound hypotension, and bradycardia (often lasting for days) follows cord injury and there may be a compromise of an already damaged cord. b. Local microcirculatory damage: may be due to mechanical disruption of capillaries, hemorrhage, thrombosis and loss of autoregulation. c. Biochemical damage: may occur due to excitotoxin release (glutamate), free radical production, arachidonic acid release, lipid peroxidation, eicosanoid production, 44 cytokines and electrolyte shifts.
Mechanism of Spinal InjurySection- 3

Secondary Injury Cascade Current understanding
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Section- 3
Primary Neurological damage Direct trauma, haematoma& SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis Secondary damage Hypoxia Hypoperfusion Neurogenic shock 46 Spinal shock
Section- 3
Patho-physiology Of Spinal Injury Secondary -
Mechanism of Spinal Injury-
Hypoxia
Lesions above C5 damage to
Injury
diaphragm leads to 20% reduction in vital capacity Rx Phrenicn. pacing Lesions at D4-6 reduces vital capacity if < 500ml patient is ventilated Intercostal nerve paralysis Atelectasis poor cough V/Q mismatch Reduced compliance of lung muscle 47 fatigue.
Section- 3
Neurogenic shock
Lesions above D6 Minutes hours (fall of catecholamines may
Injury
take 24 hrs) Disruption of sympathetic outflow from D1 L2 Unapposed vagal tone Peripheral vasodilatation Hypotension, Bradycardia& Hypothermia BUT consider haemmorhagic shock if injury below D6, other major injuries, 48 hypotension with spinal fracture alone
Section- 3
Spinal shock
Transient physiological reflex
Injury
depression of cord function concussion of spinal cord Loss anal tone, reflexes, autonomic control within 24-72hr Flaccid paralysis bladder & bowel and sustained Priapism Lasts even days till reflex neural arcs below the level recovers.
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Section- 3
Factors affecting the severity of a spinal lesion

Loss of neural tissue obvious. Vertical level Higher up, the greater the damage. Transverse plane What 50 Diameter has a lesion.
Mechanism of Spinal InjurySection- 3

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The orthopedic evaluation will typically include -
Section- 4
Fundamentals of Assessment & DiagnosisSpinal Injury Patients

History-Complete medical history. Physical Examination- Physical
General Systemic General Specific
examination to assess mobility, strength, and alignment.
Biochemical/ Laboratory Tests

Ultrasound scans
Imaging Studies X-Ray CT Scan Discography MRI Bone Scan
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FNAC
Section4
Fundamentals of Assessment & Diagnosis of Spinal Injury -
Fundamentals of Spinal Injury Diagnosis Diagnostic Evaluation of Spinal Injury-
Complete Medical History Physical Examination Biochemical & Radiological Evaluation

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Section4
Diagnostic Evaluation of Spinal Injury-
Complete Medical Common features History of spinal injuries are-
Clinical features Pain Breathing difficulty Sensitivity to stimuli Muscle spasms Loss of sensation Loss of reflex function Loss of autonomic activity Loss of bowel control Loss of bladder control Sexual dysfunction Loss of function, such as mobility or sensation 54 Paralysis.
Section4
Clinical features
Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function. Motor level = the last level with at least 3/5 (against gravity) function NB: this is the most important for clinical purposes Sensory level = the last level with preserved sensation Radiographic level = the level of fracture on plain X-Rays / CT scan / MRI NB: spine level does not correspond to spinal cord level below the cervical region. 55
Diagnostic Evaluation of Spinal Injury-
Section4
Patient Assessment
History Previous cardiovascular
Complete Medical History -
problems Pulmonary diseases Endocrine dysbalance Hepatic dysfunction Renal insufficiency Neurological illness
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Section4
A physical assessment is
Physical Examination
mandatory to detect putative intraoperative complications The physical examination complements the history and helps to detect abnormalities not apparent from the history. Examination of healthy asymptomatic patients should minimally consist of measurement of vital signs 57 (blood pressure, heart rate,
Section4
Examination of Spine Look
Skin Shape and posture Feel Tenderness Move Flexion / Extension Rotation / Lateral flexion
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Section4
Examination of Spine
Signs with patient lying face
downwards Bony outlines Tenderness Sensations and Power Femoral stretch test Signs with patient lying on his back Straight leg raising test (sciatic stretch) Neurological examination of lower 59 limbs
Section4
OrganSpecific Assessment
Airway Assessment A careful airway assessment
should be made with regard to: Previous difficulty in intubation Degree of mouth opening Size of the tongue Visibility of the pharynx The state of dentition Restriction of neck movement Stability of the cervical spine 60
Section4
Respiratory System
to the extent of the surgical procedure and the preoperative patient Condition, the respiratory function should be assessed with pulmonary function Testing including blood gas analysis in patients with: Asthma Chronic obstructive pulmonary disease Chronic intrinsic restrictive pulmonary diseases such as fibrosis and sarcoidosis 61 Extrinsic restrictive pulmonary
Fundamentals of Assessment & Diagnosis of Spinal Injury According
Section4
Cardiovascular Assessment
cardiac morbidity is one of the major challenges for the anesthetist. The elderly patient population presenting for spinal surgery has substantially increased over the last decade. Consequently, the incidence of spinal surgery in patients with coronary heart disease has increased. Special attention must be paid to those patients at increased risk and where coronary heart disease has not been formally assessed. This patient population represents the vast majority. As well as surgery-related risk, is recommended as its predictive value has been confirmed to62 be very high in elective non-cardiac surgery.
Fundamentals of Assessment & Diagnosis of Spinal Perioperative Injury -
Section4
Neurological Assessment
A neurological examination of the patient
should be made preoperatively including Assessment of gait, motor or sensory deficits and reflexes. This should be documented since the anesthesiologist has a responsibility to avoid further neurological deterioration during maneuvers such as tracheal intubation and patient positioning. Congenital kyphosis and scoliosis, postinfectious scoliosis, neurofibromatosis And patients with skeletal dysplasias carry an increased neurological risk as well as 63 patients with neurological deficits prior to
Section4
Routine Pre-operative Investigations1. Routine Blood tests. 2. Kidney, Liver function tests. 3. Lungs, Heart and Neurological assessments. Bone pathology
specific Investigations-
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Section4
Radiological Evaluation -
The diagnosis of spine conditions or diseases is based on several factors including history of pain, evaluation an physical examination, and specific diagnostic tests. Each has advantages and disadvantages, and a specific purpose. Testing may include one or more of the following: Plain x-rays

AP and lateral views Oblique views PA view of S.I. Joint
Computed tomography (with
mylography) MR imaging Radioisotope scanning Discography and facet joint
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X-RAY
X-rays of the spine reveal bone changes such as those seen in arthritis or scoliosis (curvature of the spine). They do not show nerves or discs. Helpful in diagnosing Bone spurs, Malignancy, Infection, or Dual Fractures. Absorptiometry (Dexa Energy X-ray scan) : Dexascan is used specifically to assess a patients risk of fracture by detecting osteoporosis of the vertebral bodies, which is a thinning of the bones as we age and a possible source of Bone 66 disorders.
Section4
Fundamentals of Assessment & Diagnosis of Spinal Injury -exam Screening
Stenosis cannot be diagnosed
Instability such as scoliosis or listhesis
Section4
CT - SCAN
Excellent Bony Detail
Difficult to diagnose stenosis
Replaced by MRI
May be useful for those who cannot have an
MRI
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Section4
MYELOGRAPHY
Fundamentals of Assessment & Diagnosis of Spinal Injury Invasive 1% spinal headache Recurrent stenosis Inability to obtain MRI
Excellent for intra-canal pathology Poor for foraminal pathology Replaced by MRI
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Section4
CTMYELOGRAPHY Excellent for recurrent stenosis Invaluable in surgical planning
Excellent visualization of spinal canal
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Section4
Fundamentals of Assessment & Diagnosis of Spinal Injury Image showing a normal disc at level L4/5 (Adams I) and severe disc degeneration with contrast medium in the spinal canal of L5/S1 (Adams V).
Discography -
Indications for discography to differentiation of symptomatic and asymptomatic
Disc alterations Disc degeneration Annular tears (high intensity zones) Endplate changes (modic changes) Minor disc protrusions with 70
questionable nerve root compromise
Section4
MRIMagnetic Resonance Imaging

Non-invasive Gold standard Soft tissue visualization
Expensive Patient cooperation Claustrophobia Open MRI

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Section4
MRIMagnetic Resonance Imaging
Sagittal images Visualization of foramen
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Section4
MRI- OR - CT scan
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Section4
Bone ScanWhy We Use Bone Scans
Bone scans provide surgeons with a detailed assessment of areas of abnormal bone activity. This test can be important for diagnosing spinal problems such as: Tumor Infection Fracture Arthritis or inflammation Bone scans are highly sensitive and can reveal abnormalities that are too small to appear on 74 other tests such as x-rays, MRI's, or CT Scans.
Section4
Fundamentals of Assessment & Diagnosis of Spinal Injury Nerve conduction studies
EMG-NCS
Electromyography
EMG is likely of greater utility in FBSS than in primary low back pain and sciatica. Greatest use is for establishing the presence of a peripheral neuropathy May be helpful for defining a feigned neurological deficit 75 Rarely using in decision-making
Fundamentals of Spinal Injury Management-
Fundamentals of Spinal Injury Management Medical Management Conservative (General) Conservative (Medical) Surgical Management
Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation
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Section- 5
Section- 5
Medical Management
Conservative Aim is to prevent extension of (General)primary injury, to reduce secondary injury and to treat complicationsConservative Follow ATLS principles(Medical)Airway; protect Spine Breathing Circulation Disability, Dx and Rx shock Ease patient & Treat Secondary survey. 77
Milwaukee Protocol for Spinal Immobilization
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Section- 5
Conservative Primary (General)-
(Pre-hospital) management-
Initial treatment of patients with cord injury focuses on two aspects preventing further damage and resuscitation.
Immobilization with a hard cervical collar (in case of cervical spine injuries) and care in transportation of patient is of paramount importance if the spine is unstable.
Resuscitation is aimed at airway maintenance, adequate oxygen saturation of peripheral blood, restoring blood pressure to acceptable limits, preventing bradycardia, done 78 simultaneously to prevent any ischemic
Section- 5
Fundamentals of Spinal Injury ManagementImmediate ManagementGoals:
Conservative(General) Resuscitation according to ATLS guidelines . Determination of neurological injury Prevention of neurological deterioration. Ongoing ID & Tx of assoc injuries Prevention of complications Initiation of definitive management 79 32 for
Section- 5
Conservative (General)
Breathing beware patient with C3,C4 or C5 lesion who initially has adequate respiratory effort who may progress to ventilatory failure Circulation Shock common but spinal shock is a diagnosis of exclusion CVP/PAWP monitoring usually unnecessary Immobilization Cervical spine should be immobilised in neutral position (ie position obtained when looking straight ahead) Children <8 yrs may require back elevation 80 with padding to achieve this position.
Section- 5
Conservative (Medical)-
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Section- 5
Conservative(Medical)Conservative treatments of spinal disorders have improved significantly over the years. Of the many conservative non-surgical treatments that are currently available, a few of the most commonly practiced treatments are Epidural Steroid Injection Intradiscal-thermoplasty (IDET) Nucleoplasty Facet Injections, and/or Medial Branch Blockade 82 Radio Frequency
Section- 5
Surgical Management Conventional Spinal Surgery Minimally Invasive Spinal Surgery Endoscopic Spinal Surgery Laser Spinal Surgery Intra-discal electrical Surgery
Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation
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Section- 5
Surgical Management -
Depending on the
circumstances, when surgery is required. Surgery may be considered if the spinal cord is compressed and when the spine requires stabilization. The surgeon decides the 84 procedure that will provide the
Section- 5
Types of Spinal Surgery -
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Section- 5
Spinal Decompression
Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots. Discectomy
Laminectiomy Laminiotomy Foraminectomy Foraminiotomy
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The following are common techniques for decompression :
Section- 5
Spinal Decompression
Diskectomy- This involves removing a portion of a disk

to relieve pressure on the nearby nerve roots. Laminotomy or laminectomy- These procedures involve removing a small part of the bony arches of the spinal canal, called the lamina. During a laminotomy, just a section of the lamina is removed. During a laminectomy, the entire lamina is removed. Removing the lamina increases the size of the spinal canal, relieving pressure. Foraminotomy or foraminectomy- Both procedures are performed to expand the openings for the nerve roots to exit the spinal cord by removing some bone and other tissue. A foraminectomy generally refers to a procedure that removes a large amount of bone and tissue. Osteophyte removal- This involves removing bony growths called osteophytes or bone spurs. Corpectomy- This is surgery to remove the body of a vertebra, as well as the disks.A combination of techniques may be used; and in some cases, fusion of the vertebrae also is needed to stabilize the spine. 87
Section- 5
Surgical Management Indications
Surgical Decompression and/or Fusion-
Decompression of the neural elements (spinal cord/nerves) Stabilization of the bony elements (spine) Timing Emergent Incomplete lesions with progressive neurologic deficit
Elective Complete lesions (3-7 days post injury) 88 Central cord syndrome (2-3 weeks
Section- 5
Spinal Fixation /Fusion ( Stabilization )

Goals of Spinal Stabilization: Prevent curve progression Improve sitting balance and tolerance (in non-ambulators) Reduce repositioning Reduce pain
Spinal Stabilization
Vertebroplasty
Kyphoplasty
Total Disk Replacement
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Section- 5
Fundamentals of Spinal Injury Management(Also known as spondylodesis or spondylosyndesis)
Spinal Fusion
Spinal fusions are considered medically necessary for spinal instability associated with any of the following conditions: Epidural compression or vertebral destruction from tumor Idiopathic scoliosis over 40 degrees Instability after debridement for infection Neural compression after spinal fracture Pseudarthrosis Spinal infections (including tuberculosis, osteomyelitis, discitis) Acute cauda equine OR acute spinal cord compression syndrome Acute spinal fracture from documented trauma. Intra-operative spinal instability. 90
Patients requiring spinal fusion have either neurological deficits or severe pain which has not responded to conservative treatment.
Section- 5
Types of spinal fusion
Posterolateral fusion places the bone graft between the

transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebra attaching to a metal rod on each side of the vertebrae. Interbody fusion places the bone graft between the vertebra in the area usually occupied by the intervertebral disc. Three types of interbody fusion are:
Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision Posterior lumbar interbody fusion (PLIF) - the disc is accessed from a posterior incision Transforaminal lumbar interbody fusion 91 (TLIF)
Section- 5
Dynamic
Spine Stabilization
Spinal Stabilization
Indications Herniated disc, Spinal stenosis, Degenerative Disc Disease. Spinal Stenosis is blockage in the spinal canal and associated nerve ways. A Herniated Disc (commonly known as "slipped disc") is when a spinal disc loses its normal shape as can cause pressure on nerves and this results in pain, numbness, and tingling. Dnamic spine stabilization is not appropriate for everyone and as with any 92 surgery there are possible complications.
Section- 5
Non-fusion spinal stabilization devices -
a . Dynamic posterior spinal stabilization with Dynesys (Image Zimmer, Inc. used by permisson. b . Interspinous process distraction devices (e.g. X-stop) limit extension motion and unload the facet joints. The aim is to improve functional spinal stenosis by indirect widening of the 93 spinal canal.
Section- 5
Fundamentals of Spinal Injury ManagementCore Messages
Spinal instrumentation is usually

combined with spinal fusion The type of instrumentation and the surgical approach should follow the degree of instability Consolidated fusion may relieve the implant from stress Implant failure is a result of instant overload or of cyclic loading (fatigue) If fusion is delayed and/or the wrong implants are chosen, instrumentation will 94 ultimately fail
Spinal Instrumentatio n-
Section- 5
Fundamentals of Spinal Injury ManagementCage designs
Interbody Fusion Technique
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Section- 5
Dynamic Stabilization or Fusion !
Spinal FusionThe goal of spinal fusion surgery

is to provide relief from the pain you have been having and make your spine more stable. After surgery, your ability to move should improve, and you can get back to doing the daily activities you may have been missing. The Spinal Stabilization System is a newer concept in the surgical treatment of lower back and leg pain -- one that uses flexible materials to stabilise the spine and offers a potential alternative to traditional fusion.
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Section- 5
Spinal Fixation
Spinal fixations are considered medically necessary for spinal instability associated with any of the following conditions:
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Section- 5
Spinal Instrumentation -
Spinal instrumentation should provide

early and safe mobilization of the patient For achieving bony fusion sufficient segmental stability and appropriate load sharing are essential Absolute stability may interfere with fracture healing due to stress-shielding of the bone graft Rigid (multi-)segmental instrumentation may cause adjacent segment overload. 98
Section- 5
Surgical Management Core Messages
To support the spine when its structural

integrity is severely compromised (iatrogenic, traumatic, infectious or tumorous) To prevent progression or to maintain the achieved profile after correction of spinal deformities (scoliosis, kyphosis, spondylolisthesis) To alleviate or eliminate pain originating from various anatomical structures by fusing or stiffening spine segments and 99 thereby diminishing movement
Goals of Spinal instrumentation -
Section- 5
Pedicle Screw positioning-
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Section- 5
Fundamentals of Spinal Injury ManagementFundamentals of Spinal Injury Management-
Thoracic pedicle screw positioning Trans-laminar screws
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Section- 5
Surgical Management Cage kinematics -
Stand-alone intervertebral cages for spinal fusion exhibit poor stabilization in extension. a Extension is normally partially limited by the facet joints. b Following the insertion of an interbody cage, the facet joints may 102 be distracted, c thereby increasing segmental mobility.
Section- 5
Designs of total disc arthroplasty
Current intervertebral disc prostheses differ in the bearing material used (polyethylene or metal alloys) and have either a fixed (constrained) Center of rotation - (e.g. a Prodisc, Synthes) or follow the segmental helical axis of motion (semi-constrained) as in b the Charit e prothesis (DuPuy Spine Inc.).
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Section- 5
Surgical Management Postoperative
Care - surgery is prone to Major spinal
complications but can be minimized with proper post-operative care. Despite advances in anesthesia care and surgical techniques, major surgery is still prone to undesirable consequences such as:
Infection
Thromboembolic complications Cardio-respiratory morbidity Cerebral dysfunction Postoperative nausea and vomiting Gastrointestinal paralysis Pain 104 Fatigue
Section- 5
Fundamentals of Spinal Injury The Management
Postoperative Care and Pain Management -
necessity for careful postoperative assessment of the different organ systems is self-evident Perioperative tachycardias are often combined with ischemic episodes, and their treatment is mandatory because of the high mortality of perioperativemyocardiac infarction Intensive insulin therapy can reduce morbidity and mortality Following cervical spine surgery, perform airway assessment before extubation. Suction drainage and close surveillance minimize the risk of unrecognized bleeding Aggressive postoperative pulmonary care minimizes the 105 risk of respiratory complications
Section- 5
Patients about whether they should see an orthopedic surgeon or a neurosurgeon. The spine is an area of territorial overlap between these two surgical disciplines. In general, degenerative disease of the neck is more likely to be referred to a neurosurgeon while the more complex disorders of the lumbar spine, particularly those requiring fusions, will probably be 106 dealt with by an orthopaedic surgeon.
Who should Perform Spine Surgery? are sometimes confused
Section- 5
Some spinal operations fall entirely in

the realm of the orthopaedic surgeon, for example correction of major bony deformities Some conditions are solely the responsibility of neurosurgeons, for example cysts or tumours within the spinal cord itself. Occasionally the combined skills of both specialists are needed. There remain a number of conditions which can be dealt 107 with adequately by either specialist and
Section- 5
Fundamentals of Spinal Injury ManagementFundamentals of Spinal Injury ManagementCore Messages
Surgical Management - Surgical
Approaches Preoperative planning of the
procedure is key to surgical success An in-depth knowledge of the surgical anatomy is a prerequisite for successful surgery. Detailed anatomical knowledge helps to avoid serious complications. 108
Section- 5
Surgical Approaches -
Optimal patient positioning is essential

to facilitate the approach and avoid complications. Use an image intensifier or radiographic control to avoid wrong level surgery. A profound anatomical knowledge of screw trajectories is a prerequisite for safe spinal stabilization techniques. Computer assisted surgery does not compensate for insufficient anatomical knowledge and can be dangerous in 109 inexperienced hands
Rehabilitation
Section- 6
Rehabilitation after spinal injury (SI) focuses on the patient learning how to live life when faced with physical, occupational, and emotional challenges. After SI, everything can change, and you can face many issues including mobility, regular exercise and maintaining a level of fitness, communication challenges, and activities of daily living. Rehabilitation may be accomplished at 110 a hospital, outpatient clinic, home, or a
Section6
Rehabilitation
Accredited rehabilitation centers provide SCI patients with a team of professionals and many resources. Some of the professionals include:
Occupational Therapist Physiatrist. Physical Therapist: Rehabilitation Nurse. Speech and Language Pathologist. Therapeutic Recreational Specialist. Vocational Rehabilitation Therapist. Rehab Psychologist
111
36
Section6
Rehabilitation
112
39
Section6
Rehabilitation
Neurological disorders are the most complicated problems known to medical science today, and we require the best scientific minds and technology in order to find cures.
W. Dalton Dietrich, Ph.D., scientific director, The Miami Project to Cure Paralysis
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40
Prognosis
The main determinant of outcome is the patient's neurological grade at the time of admission with patients having complete motor and sensory myelopathy showing the worst prognosis. Other predictive factors include rectal tone status, admission blood pressure and pulse status, reflexes, and medical and surgical management since injury. The time course of recovery is also prolonged and recovery itself often incomplete. Taking all grades and locations into considerations a study concluded that while the majority of cases improved within a year, even at 3 years post injury 23.3% continue to improve whereas 7.1% deteriorated. The trend continued in the 5th year post injury also with 12.5% and 5.5% respectively showing further improvement and late deterioration. Hence 114 prolonged rehabilitation at a comprehensive spinal rehabilitation center is the management of spinal cord injuries.
Core Messages
The most commonly examined predictors of surgical outcome can categorized into the following groups -
Generally consistent predictors of poor outcome -
115
Generally consistent predictors of poor outcome -
Health behavioral and lifestyle factors Smoking (especially for fusion) Psychological factors Psychological distress (e.g. Depression, anxiety), especially in patients with chronic pain Sociological factors- Family reinforcement of pain, especially 116 in patients with chronic pain
Complications of Spinal Injury/Surgery Skin Breakdown Osteoporosis and Fractures: Pneumonia, Atelectasis, Aspiration: Heterotopic Ossification: Spasticity: Autonomic dysreflexia: Deep vein thrombosis: Cardiovascular disease: Syringomyelia Neuropathic/Spinal Cord Pain Respiratory Dysfunction Miscellaneous pressure sores, Greatly increase cost and morbidity. Pokilothermia in patients with lesion above T1hyponatraemia common in 117 first week.
Complications of Spinal Injury There are many complications of spinal Injury the followings are most common -
Complications of Spinal Surgery -
There are many complications of spinal Surgery, the followings are most common -
General Complications Anesthesia Complications Bleeding Infection Blood Clots CSF leak / Dural Tear Lung Problems Persistent Pain Nerve Complications Nerve Injury Spinal Cord Injury / Paresis /Paralysis Sexual Dysfunction / Incontinence Implant & Fusion Complications Delayed Union or Nonunion Hardware Fracture Implant Migration 118 Pseudarthrosis
Recent Trends in Spine Surgery Minimally Invasive Surgery(MIS) Dynamic stabilization- Motion prevention Artificial disc replacement Endoscopic Spinal Surgery Laser Spinal Surgery Intra-discal electrical Surgery And Bio-absorbable Implant implantation
119
Pre-hospital & hospital both phases are equally Section- 7 important for SI management. Surgical intervention improves recovery period, quality of life and Rehab, reduces morbidity/ mortality . SI is neglected and poorly managed. Research is sparse and data is missing. The demographics, epidemiological pattern of SC in the developing world is different from the developed world and this should be considered while formulating polices for the SI in future. Trauma evacuation protocols need to be developed and pre hospital care of suspected SI patient should be improved. Regional and national spinal injury centers 120 providing comprehensive treatment and
121
At Shaheed Suhrawardy Medical College Hospital, Dhaka-1207.
At Shaheed Suhrawardy Medical College Hospital, Dhaka.

Serial no-
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' &traumatology-
Diagnosis
Operation
Total case 44
1.
PLID
(Prolapsed inter-vertebral disk).
Surgical
decompression/Discectomy/ Laminectomy/Epidural steroid).
2. 3. 4. 5.
Spinal TB/ Spinal Collapse. Spinal Injury Spinal Tumor Spinal Osteomyelitis
Spinal Fixation Spinal Fusion Spinal Tumor Removal Clearance
13 5 10 13
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' & traumatologySpinal Tumor 6% Spinal TB/ Collapse 16% Other 28% PLID 50% Others 16%
Spinal osteomyelitis 12%

Serial no-
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Depa rt m ent o f o rt ho pedics & t raum at ology Diagnosis operation Total case 35
1.
PLID
(Prolapsed intervertebral disk).
Surgical
decompression/Discectomy/Lamin ectomy/Epidural steroid).
2.
Spinal TB/ Spinal Collapse.
Spinal Fixation
14
3.
4. 5.
Spinal Injury
Spinal Tumor Spinal Osteomyelitis
Spinal Fusion
Spinal Tumor Removal Clearance
9
3 10
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' & traumatology -
PLID Spinal osteomyelitis
Spinal TB/ Collapse Others
Spinal Tumor
17%
11% 16% 12% 56% 4%
Case -1
Spinal Surgery:
Patient Name: Ms. Jhorna Begum, Age:17 years. Indication/ Diagnosis: Spinal TB with compression # body of L3 with posterior angulations - 45 ( on TB medication for 6 weeks) & history of fall. Name of operation: Clearance & Spinal fixation with rod and pedicle screw. Dated: 23rdJuly/ 2011. Venue: Shaheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh. Department Of Orthopedics' &Traumatology. Team Members: Associate Professor Dr. Sheikh AbbasUddin Ahmed Associate Professor Dr. Paritosh Ch. Debenath Assistant Professor Dr. Kazi Shamimuzzaman Assistant Professor Dr. ATM BaharUddin Dr. Aminur Rahman Anesthesiologist :
Post-operative Care & follow-up -
Case -2
Case -3
Basic Spinal Instruments :

Spinal Surgery Team

At ShSMCH.
Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh.

Fundamentals of - Spinal Injury & Management, and Spinal Surgery: at - Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladeh

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