2. Epidemiology
Incidence: 15,000 new cases/year
Prevalence: 1,50,000 cases and rising
Prime occurrence: males(85%), peak
of their productive lives
Most common mechanism in India
RTA or fall from heights
Cervical spine injury occurs in 44% of
spine trauma and most common Singh G, Prakash R, Bhatti VK, Mahen A.
Spinal cord injury in organizational setup -
A hospital based descriptive study. J Mar
Med Soc 2019;21:46-50
3. Introduction
• All trauma patients have a cervical spine injury until proven otherwise
• Cervical spine clearance defined as confirming the absence of cervical spine injury
• important to clear cervical spine and remove collar in an efficient manner
• cervical clearance can be performed with
• physical exam
• radiographically
• Missed cervical spine injuries
• may lead to permanent disability
• careful clinical and radiographic evaluation is paramount
• high rate of missed cervical spine injuries due to
• inadequate imaging of affected level
• loss of consciousness
• multisystem trauma
• cervical spine injury necessitates careful examination of entire spine
• noncontiguous spinal column injuries reported in 10-15% of patients
8. In-Hospital Phase
Oral secretions should be cleared.
Modified jaw thrust and insertion of an oral airway
Intubation may be required in high SCI or if consciousness is
depressed.
Ideal technique : Fiberoptic intubation with cervical spine
control.
Alternative: Blind nasotracheal or oral intubation with in-line
immobilization .
Manual in line stabilisation of the neck is maintained
throughout a rapid sequence induction of anaesthesia.
Airway
9. In-Hospital Phase
Manual in line
stabilisation of
the neck is
maintained
throughout a
rapid sequence
induction of
anaesthesia.
Airway
10. In-Hospital Phase
SpO2 should be maintained above 95%
Assisted ventilation instituted if required
If a complete spinal cord injury occurs at
the C4 level or above, the diaphragm will
be paralyzed, and the individual will not
be able to breathe without external
assistance.
Breathing
11. In-Hospital Phase
Neurogenic shock occurs only in the presence of acute SCI above T6.
Most patients will stabilise with fluid loading alone but vasopressors
and ionotropic support may be needed in some patients
Circulation
Haemorrhagic shock : clinical findings may be affected as autonomic
dysfunction prevents tachycardia and peripheral vasoconstriction.
Hypotension and/or shock with acute SCI at or below T6 are caused by
haemorrhage
An adequate blood pressure should be maintained to perfuse
the cord and decrease secondary injury
13. Physical examination
After the ABC have been taken care of, the patient is gently log rolled
and whole of the spine is palpated for tenderness or a palpable step-off
deformity.
Neurogenic shock, Incontinence of bowel, bladder and penile erection
indicate severe spine injury.
15. Diagnosis of spinal injuries: clinical
evaluation
Inspection and palpation: Occiput to Coccyx
• Tenderness
• Gap or Step
• Edema and bruising
• Spasm of associated muscles
16. Diagnosis of spinal injuries: clinical
evaluation
Neurological assessment
• Sensation
• Motor function
• Reflexes
• Rectal examination
18. Neurological assessment: Motor
C5: Deltoids/biceps
C6: Wrist extensors
C7: Elbow extensors
C8: Finger flexors
T1: Finger Abductors
L2: Hip flexors
L3: Knee extensors
L4: Ankle dorsiflexors
L5: Long toe extensors
S1: Ankle plantar flexors
Grading Scale: 0-5
0: total paralysis
1: palpable or visible contraction
2: active movement; gravity eliminated
3: active movement: against gravity
4: active movement: against some resistance
5: active movement: against full resistance
NT: not testable
19. Neurological assessment: Rectal
Tone: the presence of rectal tone in itself does not indicate an
incomplete injury
Sensation
Volition: A voluntary contraction of the sphincter or the presence of
rectal sensation supports the presence of a communication between
the lower spinal cord and supraspinal centers – favorable prognosis
Bulbocavernosus reflex:
Positive: the presence of this reflex implies the lack of supraspinal
input to the sacral outflow and is suggestive of a complete spinal
injury
Negative: absent in spinal shock
20. Neurological Classification:
Use the ASIA International standards
Motor and sensory assessment
ASIA Impairment Scale (A-E)
Clinical Syndromes (patterns of incomplete injury)
21. Spinal Cord Injury grading
systems(SCI)
American Spinal Injury Association and the
International Medical Society of Paraplegia
(ASIA/IMSOP) impairment scale
Motor level: most caudal key muscle with
at least grade 3 power
Sensory level: most caudal segment with
normal sensory function
Complete versus Incomplete: evidence of
neurological function distally, including
preservation of perineal sensation (sacral
sparing)
23. ASIA IMPAIRMENT SCALE
A = Complete: No motor or sensory function is preserved in the
sacral segments S4-S5
B = Incomplete: Sensory but not motor function is preserved
below the neurological level and includes sacral segments S4-5
C = Incomplete: Motor function is preserved below the
neurological level, and more than half of key muscles below the
neurological level have a muscle grade less than 3
D = Incomplete: Motor function is preserved below the
neurological level, and at least half of key muscles below the
neurological level have a muscle grade of 3 or more
E = Normal: motor and sensory function are normal
24. A Complete loss of motor and sensory function
B Only sensory function remains
CMotor function present, but of no practical use (i.e.
person is unable to ambulate but can move legs)
D Motor function impaired (i.e. person can
ambulate but not with a normal gait)
E No neurologic impairment noted
Frankel Classification
26. •All ascending tracts from
below and descending tracts
from above are interrupted.
•Affects motor, sensory and
autonomic functions.
COMPLETE CORD TRANSECTION
27. SENSORY:
All sensations are affected.
Pin prick test is very valuable.
Sensory level is usually 2 segments below the level of
lesion.
Segmental paraesthesia occur at the level of lesion.
COMPLETE CORD TRANSECTION
28. MOTOR:
Paraplegia due to corticospinal tract involvement.
First spinal shock-followed by hypertonic hyperreflexic
paraplegia.
Loss of abdominal and cremastric reflexes.
At the level of lesion LMN signs occur.
COMPLETE CORD TRANSECTION
29. AUTONOMIC:
Urinary retention and constipation.
Anhidrosis, trophic skin changes, vasomotor instability
below the level of lesion.
Sexual dysfunction can occur.
COMPLETE CORD TRANSECTION
31. BROWN SEQUARD SYNDROME
= Hemi-section of the spinal cord
Caused by extramedullary lesions
Usually caused by penetrating trauma or tumour.
33. SENSORY:
Ipsilateral loss of proprioception due to posterior
column involvement.
Contralateral loss of pain and temperature due to
involvement of lateral spinothalamic tract.
BROWN SEQUARD SYNDROME
34. MOTOR:
Ipsilateral spastic weakness due to descending
corticospinal tract involvement
LMN signs at the level of lesion.
BROWN SEQUARD SYNDROME
37. SENSORY:
Pain and temperature are affected.
Touch and proprioception are preserved.
Dissociative anaesthesia.
Shawl like (= Cape like) distribution of sensory loss.
MOTOR:
Upper limb weakness > Lower limb
CENTRAL CORD SYNDROME
38. Commonest causes include diabetes mellitus &
neurosyphilis.
Usually occurs 10 to 20 yrs after disease onset.
POSTERIOR CORD SYNDROME
39. FEATURES :
Paresthesia in feet
Loss of proprioception and vibration in legs
Sensory ataxia
Positive Rhomberg sign
Bladder atony
Corticospinal tract involvement:
◦ Spasticity
◦ Hyperreflexia
◦ Bilateral Babinski sign - Positive
POSTERIO LATERAL COLUMN
DISEASE
40. Due to acute disc herniation or ischemia from anterior
spinal artery occlusion.
Usually caused by hyperflexion injuries
Area supplied by anterior spinal artery is affected
ANTERIOR CORD SYNDROME
41. Sudden onset of paralysis
(quadriparesis/paraparesis)
below the level of lesion.
Pain and temperature loss.
Dorsal column is
preserved.
Prognosis is poor.
ANTERIOR CORD SYNDROME
42. SENSORY :
Loss of pain and temperature.
Preservation of position and vibration.
MOTOR :
Sudden onset flaccid and areflexic paraplegia.
AUTONOMIC :
Urinary incontinence +
ANTERIOR SPINAL ARTERY
SYNDROME
44. Lies opposite to vertebral bodies of T12 and L1.
Contributes to 25% of spinal cord injuries.
Caused by flexion distraction injuries and burst
fractures.
Both UMN and LMN deficits occur.
Development of neurogenic bladder.
CONUS MEDULLARIS
SYNDROME
45. Begins at L2 disk space
distal to conus medullaris.
occurs due to:
◦ Acute disk herniation
◦ Epidural haematoma
◦ Tumour
CAUDA EQUINA SYNDROME
46. MOTOR :
Flaccid lower extremities.
Knee and ankle jerk absent.
SENSORY :
Asymmetrical sensory loss
Saddle anaesthesia
Loss of sensation around perineum, anus, genitals.
CAUDA EQUINA SYNDROME
48. DDx: CONUS vs CAUDA
FEATURE CONUS MEDULARIS CAUDA EQUINA
PRESENTATION Sudden & Bilateral Gradual & Unilateral
REFLEXES Knee present, Ankle –
(If the epiconus is
involved, patellar reflex
maybe absent but
bulbocavernosus is
spared)
Knee & Ankle –
Bulbocavernosus reflex
is absent in low CE
(sacral) lesions
RADICULAR PAIN Less severe More severe
LOW BACKACHE More Less
Ref: http://www.emedicine.com/neuro/topic667.htm
49. FEATURE CONUS MEDULARIS CAUDA EQUINA
SENSORY
SYMPTOMS
Numbness tends to be
more localized to
perianal area;
symmetrical and
bilateral; sensory
dissociation occurs.
Sensory loss of pin
prick & temperature
sensations (Tactile
sensation is spared.)
Numbness tends to be more
localized to saddle area;
asymmetrical, maybe
unilateral; no sensory
dissociation; loss of sensation
in specific dermatomes in lower
extremities with numbness and
paresthesia; possible numbness
in pubic area, including glans
penis or clitoris.
Ref: http://www.emedicine.com/neuro/topic667.htm
50. FEATURE CONUS MEDULARIS CAUDA EQUINA
SPHINCTER
DYSFUNCTION
Urinary retention and
atonic anal sphincter
cause overflow urinary
incontinence and fecal
incontinence
Tend to present early
in course of disease.
Urinary retention
Tends to present late in
course of disease
EMG Mostly normal lower
extremity with external
anal sphincter
involvement
Multiple root level
involvement; sphincters may
also be involved.
OUTCOME Less favourable More Favourable
Ref: http://www.emedicine.com/neuro/topic667.htm
52. One to two days Nerve cells become less responsive to sensory input,
resulting in full or partial loss of spinal cord reflexes. This is
known as hyporeflexia.
One to three days Initial return of some reflexes. Polysynaptic reflexes --
Bulbocavernosus Reflex,
One to three weeks a pattern of unusually strong reflexes, occurs. This is the
result of new nerve synapse growth, and is normally
temporary
One to twelve
months
Hyperreflexia continues, and spasticity may develop. This
process is due to changes in the neuronal cell bodies, and
takes much longer than the other stages
Spinal shock
53. NEXUS
N neurologic deficit (focal)
E (Etoh) alcohol/Intoxication
X extreme distracting injury
U unable to provide history(loss of consciousness)
S spinal tenderness
When to get a spine imaging
54. NEXUS
Sensitivity 99%
Negative predictive value 99.8%
Specificity 12.9%
Positive predictive value 2.7%
Hoffman JR, Mower WR, Wolfson AB, Todd KH,
Zucker MI. Validity of a set of clinical criteria to
rule out injury to the cervical spine in patients with
blunt trauma. National Emergency X-Radiography
Utilization Study Group. The New England journa
of medicine. 343 (2): 94-
9. doi:10.1056/NEJM200007133430203 -
56. Results of Canadian C-
Spine Study
8924 patients enrolled
100 % sensitivity for identifying 151
clinically important C-spine injuries
42.5 % specificity
deemed a highly sensitive decision rule for
use of C-spine radiography in alert and
stable trauma patients
The Canadian C-spine rule for radiography in alert and stable trauma patients
I G Stiell1, G A Wells, K L Vandemheen, C M Clement, H Lesiuk, V J De Maio, A Laupacis, M Schull, R D McKnight, R Verbeek, R
Brison, D Cass, J Dreyer, M A Eisenhauer, G H Greenberg, I MacPhail, L Morrison, M Reardon, J Worthington
•PMID: 11597285
•DOI: 10.1001/jama.286.15.1841
57. Imaging studies
Standard 3 views of the cervical spine (AP, lat
and odontoid)
AP and lat views of the thoracic and lumbar
spine.
The cervical spine radiographs must include
the C7-T1 junction to be considered adequate
X rays
58. Essential for evaluating
injury to the soft tissues and ligaments, discs,
intrinsic cord damage (oedema, hematoma, or
contusion)
Para vertebral soft tissues.
MRI is particularly useful in scenarios such as
central cord syndrome
MRI
59. CT scan cervical spine in all cases of
head injuries or intoxication at the
same time as the brain CT.
CT should be done when plain X-Ray
is inadequate particularly upper
cervical spine injuries and C7-T1
junction
Better delienation of bony anatomy in
axial, frontal and coronal planes
CT Scan
60. A patient of suspected spinal cord injury
should not be cleared and spine
immobilisation should not be removed
unless all the radiologic investigations
have been seen and cleared by an
experienced physician
IMPORTANT
61. How to read the Lateral Cervical Spine
X-Ray
Lateral cervical spine x-
ray must visualize
entire cervical spine .
A film that does not
show the upper border
of T1 is inadequate
Caudal traction on the
arms may help
AABCDS Adequacy, Alignment, Bone,
Cartilage, Disc, Soft tissues
62. Lateral Cervical Spine X-Ray
The anterior vertebral line,
posterior vertebral line, and
spinolaminar line should have a
smooth curve with no steps or
discontinuities
Malalignment of the posterior
vertebral bodies is more
significant than that anteriorly,
which may be due to rotation
A step of >3.5mm is
significant anywhere
63. Anterior subluxation of one
vertebra on another
indicates facet dislocation
Less than 50% of the width
of a vertebral body implies
unifacet dislocation
Greater than 50%
implies bilateral facet
dislocation
This is usually
accompanied by widening
of the interspinous and
interlaminar spaces
Lateral C-Spine X-
ray
64. Lateral C-Spine X-ray
Vertebral body and intervertebral disc
examination reveal compression and
burst type injuries
Bodies normally regular cuboids similar
in size and shape to the vertebrae
immediately above and below (not
C1/C2)
Anterior wedging of vertebral body or
teardrop fractures of antero-inferior
portion of body implies compression
fracture
65. Lateral C-Spine X-ray
Loss of height of an intervertebral
disc space may indicate disc
herniation
Soft tissue shadow is created by
pharyngeal and prevertebral tissue
Nasopharyngeal space (C1) - 10 mm
(adult)
Retropharyngeal space (C2-C4) - 5-7
mm
Retrotracheal space (C5-C7) - 14
mm (children), 22 mm (adults).
66. AP View
The height of the cervical
vertebral bodies should be
approximately equal
The height of each joint
space should be roughly
equal at all levels.
Spinous process should be
in midline and in good
alignment.
67. Odontoid View
An adequate film should include the entire
odontoid and the lateral borders of C1-C2.
Occipital condyles should line up with the
lateral masses and superior articular facet of
C1.
The distance from the dens to the lateral
masses of C1 should be equal bilaterally.
The tips of lateral mass of C1 should line up
with the lateral margins of the superior
articular facet of C2.
The odontoid should have uninterrupted
cortical margins blending with the body of
C2.
69. Plain Film
Radiology
If lower cervical spine difficult to see,
caudal traction on the arms may be used to
improve visualization
Repeated attempts at plain radiography are
usually unsuccessful
If the lower cervical spine is not visible, a CT
scan of the region is then indicated
70. MRI
Ideally all patients with an abnormal
neurological examination should be
evaluated with an MRI scan
Patients who report transient
neurological symptoms but who have a
normal examination should also
undergo an MRI assessment of their
spinal cord
71. •MRI
•Advantages
•highly sensitive for detection of soft tissue injuries
•disc herniations
•posterior ligament injuries
•spinal cord changes
•Disadvantages
•high rate of false positives
•only effective if done within 48 hours of injury
•can be difficult to obtain in obtunded or intoxicated patients
•MR and CT angiography
•Advantage
•effective for evaluating vertebral artery
72. Indication for spinal MRI
The main indications of MRI in spinal trauma include :
1. Radiographic and/or CT scan findings suggestive of ligamentous injury, such as prevertebral hematoma,
spondylolisthesis, asymmetric disc space widening, facet joint widening or dislocations, and inter-spinous
space widening.(unstable injury )
2. To look for epidural hematoma or disc herniation before attempting a closed reduction of cervical facet
dislocations.
3. To identify spinal cord abnormalities in patients with impaired neurological status.
4. To exclude clinically suspected ligamentous or occult bony injuries in patients with negative radiographs.
5. To determine the stability of the cervical spine and assess the need for cervical collar in lethargic trauma
patients.
6. To differentiate between hemorrhagic and non-hemorrhagic spinal cord injuries for the prognostic significance
as the presence of hemorrhage significantly worsens the final clinical outcome
73. According to American College of Radiology (ACR) appropriateness
criteria, MRI of spine combined with CT scan is appropriate in the setting
of acute spinal trauma if :
1. National Emergency X-Radiography Utilization Study (NEXUS) or
Canadian Cervical-Spine Rule (CCR) criteria are met and there are
clinical findings of myelopathy.
2. NEXUS or CCR criteria are met and there are clinical or imaging findings
to suggest ligamentous injury.
3. NEXUS or CCR criteria indicate imaging and the mechanically unstable
spine is anticipated.
74. T1W – anatomy and osseous fracture
STIR- edema, soft tissue, ligamentous injuries
T2W- cord edema
T2W GRE images are used to detect the hemorrhage in and around the cord
Anterior column - ALL, anterior two-thirds of the vertebral body and
anterior two-thirds of the intervertebral disc.
The middle column consists of posterior one-third of the vertebral body,
posterior one-third of the intervertebral disc, and PLL.
The posterior column consists of everything posterior to the PLL including
pedicles, facet joints and articular processes, ligamentum flavum, neural arch
and interconnecting ligaments
76. Sagittal T2 weighted image (a) shows normal anterior longitudinal ligament (short single
arrow), posterior longitudinal ligament (short double arrows) and ligamentum flavum
(long arrow). Sagittal T2 weighted image (b) shows normal wavy supraspinous ligament
(short arrow), and normal striated interspinous ligament (long arrow)
77. Sagittal short tau inversion recovery (STIR) images show complete anterior longitudinal ligament tear
(arrow, a), complete posterior longitudinal ligament tear (short single arrow, b) and ligamentum flavum tear
(long arrow, b), ligamentum nuchae tear (short double arrows, b), facet capsular injury (arrow, c), and
interspinous ligament injury (short double arrows, d). Also note the presence of thoracic vertebrae contusions
(arrows
78. Axial gradient recalled echo (GRE) image (a) and sagittal T1
weighted image (b) show the presence of a small central disc
herniation (white arrows). Also note the presence of paraspinal
muscle edema (black arrow, a)
79. Sagittal T1 weighted image (a) and axial gradient recalled echo
(GRE) image (b) show the presence of epidural hematoma
(arrows), and axial T2 weighted image (c) shows subdural
hematoma (long arrow) deep to the dura (short arrow
80. Sagittal T2 weighted image (a) and axial gradient recalled echo
(GRE) image (b) show the presence of nonhemorrhagic
contusion in the spinal cord (arrows)
81. Sagittal T2 weighted image (a) and axial gradient recalled echo
(GRE) image (b) show the presence of hemorrhagic contusion
(arrow, a)
82. Sagittal CT image in the bone window (a) did not show any CT
evidence for a fracture in this trauma patient. However, sagittal
short tau inversion recovery (STIR) image (b) shows bone
marrow edema in the superior aspect of multiple vertebrae
(arrows) suggesting bone contusions
83. CT
Scanning
Thin cut CT scanning
should be used to
evaluate abnormal,
suspicious or poorly
visualized areas on plain
radiology
The combination of plain
radiology and directed CT
scanning provides a false
negative rate of less than
0.1%
84. Role of CT imaging
Radiographs of the cervical spine detect only 60% to 80% of
fractures, even when all 3 views are obtained
CT has a higher sensitivity and specificity for evaluating
cervical spine injury than radiographs, detecting 97% to 100%
of fractures
Rapid radiological clearence of cervical spine
The most important limitation of CT is the inability to provide
screening for ligamentous and spinal cord injury
Imaging of Spine Trauma
Lubdha M Shah1, Jeffrey S Ross
•PMID: 27404215
•DOI: 10.1227/NEU.0000000000001336
85. CT of the craniovertebral junction in
the coronal (A), sagittal (B), and
parasagittal (C, D) planes shows
atlantooccipital dissociation. There
is widening (white arrow) and
anterior subluxation (red arrows) of
the atlanto-occipital articulations.
The basion dens distance is
abnormally increased as well
(yellow arrow).
Imaging of Spine Trauma
Lubdha M Shah1, Jeffrey S Ross
•PMID: 27404215
•DOI: 10.1227/NEU.0000000000001336
86. Sagittal (A) CT reconstruction, T1-weighted (B), T2-
weighted (C), and STIR (D) Acute compression fractures
of C7 and T3 are also noted (white arimages illustrate a
type 2 dens
fracture (red arrows). rows). STIR, short tau inversion
recovery.
Imaging of Spine Trauma
Lubdha M Shah1, Jeffrey S Ross
•PMID: 27404215
•DOI: 10.1227/NEU.0000000000001336
87. Sagittal STIR (A), sagittal CT (B), and parasagittal CT (C,
D) images show traumatic spondylolisthesis of C2.
There are bilateral comminuted pars interarticularis
fractures (white arrows). Anterolisthesis and inferior
angulation of C2 on
C3 are observed. A small prevertebral hematoma (red
arrow) is noted. STIR, short tau inversion recovery
Imaging of Spine Trauma
Lubdha M Shah1, Jeffrey S Ross
•PMID: 27404215
•DOI: 10.1227/NEU.0000000000001336
88. Sagittal (A) CT reconstruction, T1-weighted (B), T2-weighted (C), and STIR (D) images show a midthoracic
flexion-distraction injury. There is a burst fracture of T7 with retropulsed bone fragments. In addition to fracture of
the posterior elements, there is ligamentous injury with stripping of the ALL (white arrow) and discontinuity of the
PLL (red arrow) and supraspinous ligament (yellow arrow). Ligamentum flavum rupture with epidural hemorrhage
is also noted (blue arrow). ALL, anterior longitudinal ligament; PLL, posterior longitudinal ligament; STIR, short tau
inversion recovery
Imaging of Spine
Trauma
Lubdha M Shah1, Jeffrey S Ross
•PMID: 27404215
•DOI: 10.1227/NEU.00000000000
01336
89. Clearance of Cervical Spine Injury in Conscious,
Symptomatic Patients
1. Radiological evaluation of the cervical
spine is indicated for all patients who do
not meet the criteria for clinical clearance
as described above
2. Imaging studies should be technically
adequate and interpreted by experienced
clinicians
90. Radiographic Examination and
Clearance of Cervical Spine Injury -
Unconscious, Intubated Patients
Key Points
1. The odontoid view is unreliable in
intubated patients
2. Clinical examination is impossible in the
unconscious patient
3. Plain film radiology cannot exclude
ligamentous instability
91. C-spine clearance in unconscious, intubated patients
Standard radiological examination of cervical spine in
unconscious, intubated patients is
1. Lateral cervical spine film
2. Antero-posterior cervical spine film
3. CT scan of occiput-C3
The open mouth odontoid radiograph is inadequate in
intubated patients and will miss up to 17% of injuries to
the upper cervical spine
92. C-spine clearance in unconscious,
intubated patients
Clearance of the spine in unconscious
patients is limited by the lack of clinical
information
Incidence of unstable spinal injury in adult,
intubated trauma patients is about 10.2%
Incidence of unstable, occult spinal trauma
(not visible on plain films) is about 2.5%
93. Magnetic Resonance
Imaging in unconscious
C-Spine Trauma
Extremely sensitive at detecting soft tissue
injuries without stressing cervical spine
High false positive rate
Few good studies on the use of MRI in
clearing the cervical spine in unconscious
patients
94. Four Basic Reasons Why Cervical Spine Fractures Are
Missed By Physicians
1. Failure to obtain indicated films
2. Inadequate films
3. Misinterpretation of the films
4. Films fail to adequately visualize the
injuries