Traumatic Spine and Spinal Cord Injuries

1. Traumatic Spine and Spinal Cord Injuries Dafina M. Good, MD Emory University School of Medicine Children’s Healthcare of Atlanta Pediatric Emergency Medicine Fellow

2. 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 SCI’s • To review the radiologic evaluation of spinal trauma • To review traumatic spine fractures • To review some partial spinal cord syndromes

3. 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 SCI’s • Motor Vehicle Accidents are the leading cause of pediatric SCI (60% of cases)…with falls and sports injuries (football and diving) thereafter • M:F ratio of 2:1 • Avg age is 14 to 15 yrs old • 2006 study from the NTDB & the KID found that almost 70% of children injured in MVA’s from 1997-2000 were not wearing a seatbelt and in 30% of those cases alcohol or drugs were involved

4. Cervical Spine Anatomy

5. Spine Vertebrae Anatomy

6. Spine Vertebrae Anatomy

7. Cervical Spine Anatomy

8. Cervical Spine Anatomy

9. Atlas-Dens Relationship

10. Anatomy of the Spinal Columns

11. 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

12. Key History and PE Components • History • Cause…. MVA, Sports (Football/Diving), Falls • Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Fx’s), hyperextension (Hangman’s 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% Down’s 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 • DTR’s and rectal tone • High index for Multisystem trauma (40% of cases have associated intrabdominal injuries)

13. 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 >90% 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 • Swimmer’s 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

14. 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

15. C-spine Lateral View

16. C-spine AP View

17. C-spine Odontoid View

18. C-spine Odontoid View

19. Swischuk’s 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

20. C-spine Films

21. Predental Space Space should be no more than 5mm

22. Intervertebral Disk Spaces

23. “7yr old fell off her bunk bed 3 days ago and still has a crook in her neck”

24. C1-C2 Rotary Subluxation

25. Abnormal Odontoid View

26. Abnormal Odontoid View

27. Jefferson Fracture (C1 Burst Fracture) • Axial loading or vertebral compression • Displaced lateral masses of C1 • Predental space increased • Moderately unstable

28. Transverse Ligament Rupture

29. Transverse Ligament Rupture

30. Transverse Ligament Rupture

31. Atlanto-occipital Dislocation

32. Atlanto-Occipital Dislocation • Widening of the atlanto-occipital joint >5mm • Prevertebral swelling • Usually fatal • Patients usually apneic at the scene • 5X more common in children

33. Odontoid View

34. Type II Dens Fracture

35. Hangman’s Fracture

36. Clay-Shoveler’s Fracture • Spinous process avulsion fracture • Very stable

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

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

39. Chance Fracture AP Thoracic Spine

40. Chance Fracture • Hyperflexion injury • Lap belt injury • Transverse fractures through the VB • 50% associated with intrabdominal organ injuries • Posterior column disruption

41. 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 SCI’s 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

42. Review of Traumatic Spinal Cord Syndromes

43. Motor Innervation of the Nervous System

44. Sensory Innervation of the Nervous System

45. 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.

46. Partial Cord Syndromes

47. 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

48. 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.

49. 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

50. 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