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Spine fracture
Anatomy of The Low Back
Cont …
Spinal segment consists
of the following:
• Two vertebrae
• An intervertebral disc
between the two
vertebrae
• Two nerve roots that
leave the spinal cord,
one on each side
Functions of the spine
• 1. Protect the spinal cord,
nerve roots, and internal
organs.
2. Provide flexibility of motion.
3. Provide structural support
and balance for upright
posture.
• Spine bears the load of the
head, shoulders and arms, and
upper body. The upper body
weight is then distributed to the
hips and legs.
• The spine attempts to keep the
body's weight balanced over
the pelvis. This reduces the
amount of work required by the
spinal muscles and can
eliminate muscle fatigue and
back pain.
Denis Classification: The Three-column Concept
• 1. Anterior column consists of the
anterior longitudinal ligament and the
anterior part of the vertebral body.
• 2. Middle column extends from the
middle portion of the vertebral body to
the posterior aspect of the vertebral body
and includes the posterior longitudinal
ligament.
• 3. Posterior column includes all bony
and ligamentous structures posterior to
the posterior longitudinal ligament and
includes the pedicles, facets, spinous
processes and all associated ligaments.
• Fractures involving only the anterior
columns are considered stable, while
fractures that involve the middle or all
three columns are considered unstable.
Incidence of spine injury
• Male : female = 4 : 1
• Injury is common at the cervicothoracic and
throacolumbar regions
Mode of injury :
• RTA : 45 %
• Falls : 20 %
• Sports ( diving ) injuries : 15 %
• Acts of violence : 15 %
Injuries of the cervical spine
Common areas :
• C1 – 2 and C5 – 7 ( common )
• Neurological damage ------ 40 %
• Radiograph normal --------- 10 %
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Causes :
Fall from height
Diving injuries
RTA ( whiplash injury )
Gunshot injuries
Mechanism of injury
• Pure flexion force : fall from height
• Flexion rotation force : fall on one side of the shoulder
• Axial compression : fall of an object on the head results in
load compression
• Extension force : e.g ; whiplash injury
• Lateral flexion
• Direct injuries : assault , gunshot injury
Whiplash injury ( acceleration injury , cervical
sprain syndrome , soft tissue neck injury )
• An injury caused by the neck and head being
thrown suddenly backward then forward upon
impact.
• Impact forces the neck and head beyond their
normal range of movement, causing tissue
damage and pain.
Clinical features
Symptoms : -
Signs : -
– Headache
– Loss of motion in the
– Pain in the shoulders
neck
– Pain between the shoulder
– Neck muscle spasm
blades
– Pain in one or both arms
– Rarely : vertigo , auditory
or visual disturbance
– Neck pain/stiffness
Investigation : – Low back pain
X – ray ---- usually normal
MRI ------ to make diagnosis
Treatment
Conservative :
First aid
– First 24 hours : – an ice bag applied to the neck ( relieve inflammation)
for 20 minutes at a time,
Medication
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nonsteroidal anti-inflammatory drugs,
antidepressants,
muscle relaxants, and
cervical collar (for 2 to 3 weeks).
Range of motion exercises,
physical therapy, and
cervical traction
cervical collar
Exercise
• Movement of deep muscles in the back of
the head : Stand against a door or a wall with
your head facing forward and move your eyes
so you look towards the two, four, eight, and
10 o'clock positions. Repeat this a few times.
• Bend the back of the head carefully forward as
if taking a bow. Return to the starting position
with your head straight and facing forward.
• Draw the chin in towards your neck and bend
the head carefully forward. Return to the
starting position. Bend the head backwards far
enough to look at the ceiling. Return to the
starting position.
Cont..
• Tilt the head sideways, if possible try to maintain the
glance at a fixed point at eye level. Return to the
starting position. Repeat this action with the head
tilted to the other side.
• Turn the head as if trying to look backwards over
the shoulder, first to the left and then to the right.
Imagine following a horizontal line on the wall at eye
level.
• Place the ball between the wall and the forehead
and then try to move it around on the wall in circles
or figures of eights. Repeat the exercise, this time
placing the ball between the back of the head and
the wall.
Clinical features
•
•
•
•
•
History of trauma
Pain ,
swelling and
inability to move neck
Tenderness and palpable gap over the involved
spinous process
• Neurological involvement
• Injuries of the spinal cord at the cervical region
Nerve root involvement
Motor System Examination
Deltoid muscle
• Ask the patient to raise
both their arms in front of
them simultaneously as
strongly as then can while
the examiner provides
resistance to this
movement. Compare the
strength of each arm.
The deltoid muscle is
innervated by the C5
nerve root via the axillary
nerve.
Biceps muscle
• Test the strength of lower
arm flexion by holding the
patient's wrist from above
and instructing them to
"flex their hand up to their
shoulder". Provide
resistance at the wrist.
Repeat and compare to
the opposite arm. This
tests the biceps muscle.
The biceps muscle is
innervated by the C5 and
C6 nerve roots via the
musculocutaneous nerve.
Triceps muscle
• Ask the patient to extend their
forearm against the examiner's
resistance. Make certain that the
patient begins their extension
from a fully flexed position
because this part of the
movement is most sensitive to a
loss in strength. This tests the
triceps. Note any asymmetry in
the other arm.
The triceps muscle is innervated
by the C6 and C7 nerve roots via
the radial nerve.
Forearm extensors
• Test the strength of wrist
extension by asking the patient
to extend their wrist while the
examiner resists the
movement. This tests the
forearm extensors. Repeat
with the other arm.
The wrist extensors are
innervated by C6 and C7
nerve roots via the radial
nerve. The radial nerve is the
"great extensor" of the arm: it
innervates all the extensor
muscles in the upper and
lower arm.
Forearm flexors and the intrinsic hand muscles
• Examine the patient's hands.
Look for intrinsic hand, thenar
and hypothenar muscle wasting.
Test the patient's grip by having
the patient hold the examiner's
fingers in their fist tightly and
instructing them not to let go
while the examiner attempts to
remove them. Normally the
examiner cannot remove their
fingers. This tests the forearm
flexors and the intrinsic hand
muscles. Compare the hands for
strength asymmetry.
Finger flexion is innervated by the
C8 nerve root via the median
nerve.
Intrinsic hand muscles
• Test the intrinsic hand
muscles by having the
patient abduct or "fan out"
all of their fingers. Instruct
the patient to not allow the
examiner to compress them
back in. Normally, one can
resist the examiner from
replacing the fingers.
Finger abduction or
"fanning" is innervated by
the T1 nerve root via the
ulnar nerve.
Thumb opposition
• Test the strength of the
thumb opposition by telling
the patient to touch the tip of
their thumb to the tip of their
pinky finger. Apply resistance
to the thumb with your index
finger. Repeat with the other
thumb and compare.
Thumb opposition is
innervated by the C8 and T1
nerve roots via the median
nerve.
Iliopsoas muscles.
Hip flexion
• First test the flexion of the
hip by asking the patient to
lie down and raise each leg
separately while the
examiner resists. Repeat
and compare with the other
leg. This tests the iliopsoas
muscles.
Hip flexion is innervated by
the L2 and L3 nerve roots
via the femoral nerve.
Adductors of the medial thigh
• Test the adduction of the
legs by placing your
hands on the inner thighs
of the patient and asking
them to bring both legs
together. This tests the
adductors of the medial
thigh.
Adduction of the hip is
mediated by the L2, L3
and L4 nerve roots.
Gluteus maximus and gluteus minimus.
• Test the abduction of the
legs by placing your
hands on the outer thighs
and asking the patient to
move their legs apart.
This tests the gluteus
maximus and gluteus
minimus.
Abduction of the hip is
mediated by the L4, L5
and S1 nerve roots.
Gluteus maximus.
• Test the extension of the
hip by instructing the
patient to press down on
the examiner's hand which
is placed underneath the
patient's thigh. Repeat and
compare to the other leg.
This tests the gluteus
maximus.
Hip extension is innervated
by the L4 and L5 nerve
roots via the gluteal nerve.
Quadriceps muscle
• Test extension at the knee by
placing one hand under the
knee and the other on top of
the lower leg to provide
resistance. Ask the patient to
"kick out" or extend the lower
leg at the knee. Repeat and
compare to the other leg.
This tests the quadriceps
muscle.
Knee extension by the
quadriceps muscle is
innervated by the L3 and L4
nerve roots via the femoral
nerve.
Hamstrings
• Test flexion at the knee by
holding the knee from the
side and applying
resistance under the ankle
and instructing the patient
to pull the lower leg towards
their buttock as hard as
possible. Repeat with the
other leg. This tests the
hamstrings.
The hamstrings are
innervated by the L5 and S1
nerve roots via the sciatic
nerve.
Muscles of the anterior compartment
• Test dorsiflexion of the
ankle by holding the top of
the ankle and have the
patient pull their foot up
towards their face as hard
as possible. Repeat with
the other foot. This tests
the muscles in the anterior
compartment of the lower
leg.
Ankle dorsiflexion is
innervated by the L4 and
L5 nerve roots via the
peroneal nerve.
Muscles in the posterior compartment
• Holding the bottom of the foot,
ask the patient to "press down
on the gas pedal" as hard as
possible. Repeat with the other
foot and compare. This tests
the gastrocnemius and soleus
muscles in the posterior
compartment of the lower leg.
Ankle plantar flexion is
innervated by the S1 and S2
nerve roots via the tibial nerve.
Extensor halucis longus muscle.
• Ask the patient to move
the large toe against the
examiner's resistance "up
towards the patient's
face".
• The extensor halucis
longus muscle is almost
completely innervated by
the L5 nerve root. This
tests the extensor halucis
longus muscle.
Anatomy and Physiology
• Spinal cord is the largest
nerve in the body. Nerves
are cord-like structures
made up of nerve fibers.
• Nerve fibers are responsible
for the communication
systems of the body, which
include sensory, motor, and
autonomic functions.
• The nerve fibers within the
spinal cord carry messages
between the brain and the
rest of the body.
Cont ..
• Nerves that lie within the spinal cord
are upper motor neurons (UMNs).
They carry the messages back and
forth from the brain to the spinal
nerves along the spinal tract.
• The spinal nerves that branch out
from the spinal cord to the other
parts of the body are lower motor
neurons (LMNs). These spinal
nerves exit and enter at each
vertebral level and communicate
with specific areas of the body.
• The sensory portion of the LMNs
carry messages to the brain about
sensation from the skin and other
body parts and organs.
• The motor portion of the LMNs
send messages from the brain to the
various body parts to initiate actions
such as muscle movement.
Cont ..
• The vertebral column, or
spinal column, is made up of
4 regions : • Seven cervical vertebrae
protect the eight cervical
nerves;
• Twelve thoracic vertebrae
protect the twelve thoracic
nerves;
• Five lumbar vertebrae
protect the five lumbar
nerves;
• Five sacral vertebrae, which
are fused as one bone, help
protect the five sacral nerves
Cont …
• As the body grows, the
vertebral column grows more
in length than the spinal cord,
which usually ends between
the first and second lumbar
vertebrae.
• From this point the lumbar
and sacral nerves branch out
from the spinal cord and
descend inside the spinal
column before leaving the
vertebral column at their
corresponding vertebrae.
• Because of this fact there is a
difference between the
skeletal or bony level of
vertebral fracture and the
neurological level of spinal
cord injury
What Happens after A Spinal Cord Injury?
• Spinal cord injury (SCI) refers to any injury of the neural
(pertaining to nerves) elements within the spinal canal. SCI can
occur from either trauma or disease to the vertebral column or the
spinal cord itself.
• Most spinal cord injuries are the result of trauma to the vertebral
column. Such trauma can cause a fracture of bone or tearing of
ligaments with displacement of the bony column.
• The vertebral trauma may cause contusion with hemorrhage and
swelling of the spinal cord or it may cause a tearing of the spinal
cord and/or its nerve roots.
• The damage from the spinal cord injury can affect the nerve fibers
sending and receiving of messages from the brain to the body's
systems that control sensory, motor, and autonomic function below
the level of injury.
• It is important to distinguish between injuries that occur in the spinal
cord proper from those that occur to the conus medullaris or to the
cauda equina
Cont…
• A spinal cord injury with preservation of segments of
spinal cord below the level of injury usually
produces an upper motor neuron (UMN) type of
injury or spastic paralysis. The intrinsic reflexes
are uninhibited and become hyperreflexic and lead
to increased muscle tone, spasms, and spasticity.
• A conus medullaris injury, without preservation of
spinal cord segments below the lesion, or a cauda
equina injury produces a lower motor neuron (LMN)
type of injury or flaccid paralysis. With this type of
injury, the stimuli cannot reach the spinal cord;
therefore, the reflexes and muscle tone remain
decreased or absent (flaccid).
Cord involvement
• Complete : leads to quadriplegia or
quadriparesis
• Incomplete : here the central , lateral ,
anterior or posterior cord could be involved
Other examination
• Rectal sensastion : loss of sensation
around the anus
• Rectal motor : sphincter contraction
Investigations
• Radiography :
• AP ,lateral , open mouth and oblique view
• CT scan ( for hidden # )
• MRI (cord injury )
• Others :
• Hb % , blood grouping , bleeding time , clotting
time , electrolyte .
Treatment
Goals :
• Realign the spine
• Prevent further neurological damage
• Obtain and maintain spinal stability
At the accident site
• Resuscitation and transport
• Unnecessary neck movement should be totally
avoided
• At the hospital :
• Nonoperative :
• Four postcervical collars
• Cervical collar
• Indication :
• Stable cervical spine with no neurological injury
for 8 – 12 weeks
• Stable compression # and undisplaced
Skeletal traction
• For unstable #
• Given for 3 – 6 weeks
• Mobilise with cervical
collar
• Surgical treatment :
• Unstable injuries with
or without
neurological damage
• ORIF
Thoracic and lumbosacral spine
injuries
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Mechanism of injury :
Fall from height
RTA
Gunshot injury , assault
etc.
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Clinical features :
History of trauma
Pain
Posterior swelling
Tenderness
Palpable interspinous
gap
• Spinal shock
• Neurological involvement
Investigations
• AP , lateral and oblique view of affected
spine
• CT ( study of bony elements )and
• MRI ( bone and soft tissue )
Management
• At the site of accident :
• Careful handling of the patient
• Resuscitation and transport
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Definite Tx. At the hospital :
Stable # without neurological deficit :
Bed rest for 3 – 6 weeks
External spine supports ( brace )
Stable # with neurological deficit :
• Incomplete :
• IV steroids
• Anterior and posterior
fusion
• Rehabilitation
• Complete :
• IV steroids
• Early operative fusion
to mobilise the patient
early
• Rehabilitation
Unstable #
• Without neurological
deficit :
• ORIF and bony fusion
• With neurological
deficit :
• IV steroids
• ORIF and spinal
fusion both in
complete or
incomplete paralysis