Traumatic Spine and Spinal Cord Traumatic Spine and Spinal Cord InjuriesInjuries

Dafina M. Good, MDDafina M. Good, MDEmory University School of MedicineEmory University School of Medicine

Children’s Healthcare of AtlantaChildren’s Healthcare of Atlanta

Pediatric Emergency Medicine FellowPediatric Emergency Medicine Fellow

ObjectivesObjectives

To review the epidemiology of Spinal Cord To review the epidemiology of Spinal Cord Injuries (SCI) in childrenInjuries (SCI) in children

To review the Anatomy of the spine and spinal To review the Anatomy of the spine and spinal cord cord

To review pertinent history and physical exam To review pertinent history and physical exam findings involved in SCI’s findings involved in SCI’s

To review the radiologic evaluation of spinal To review the radiologic evaluation of spinal traumatrauma

To review traumatic spine fractures To review traumatic spine fractures To review some partial spinal cord syndromesTo review some partial spinal cord syndromes

Epidemiology of Spinal Trauma in Epidemiology of Spinal Trauma in ChildrenChildren

Spinal injury is rare in childrenSpinal injury is rare in children Higher mortality in children Higher mortality in children Pediatric vertebral injuries occur 60-80% of the time in the Pediatric vertebral injuries occur 60-80% of the time in the

cervical region (30-40% of all vertebral injuries in adults)cervical region (30-40% of all vertebral injuries in adults) Overall incidence of spinal injury in children is 1-2%Overall incidence of spinal injury in children is 1-2% Almost 1500 children are admitted to US hospitals each Almost 1500 children are admitted to US hospitals each

year for treatment of SCI’syear for treatment of SCI’s Motor Vehicle Accidents are the leading cause of pediatric Motor Vehicle Accidents are the leading cause of pediatric

SCI (60% of cases)…with falls and sports injuries (football SCI (60% of cases)…with falls and sports injuries (football and diving) thereafterand diving) thereafter

M:F ratio of 2:1M:F ratio of 2:1 Avg age is 14 to 15 yrs oldAvg age is 14 to 15 yrs old 2006 study from the NTDB & the KID found that almost 2006 study from the NTDB & the KID found that almost

70% of children injured in MVA’s from 1997-2000 were not 70% of children injured in MVA’s from 1997-2000 were not wearing a seatbelt and in 30% of those cases alcohol or wearing a seatbelt and in 30% of those cases alcohol or drugs were involved drugs were involved

Cervical Spine AnatomyCervical Spine Anatomy

Spine Vertebrae AnatomySpine Vertebrae Anatomy

Spine Vertebrae AnatomySpine Vertebrae Anatomy

Cervical Spine AnatomyCervical Spine Anatomy

Cervical Spine AnatomyCervical Spine Anatomy

Atlas-Dens RelationshipAtlas-Dens Relationship

Anatomy of the Spinal Anatomy of the Spinal Columns Columns

Pediatric vs. Adult Spine Pediatric vs. Adult Spine AnatomyAnatomy

……..……..Not just little adults!Not just little adults! Children younger than 8yrs are more susceptible to Children younger than 8yrs are more susceptible to

C-spine injuries because;C-spine injuries because; Larger head to body proportionLarger head to body proportion Higher fulcrum……. “point of maximal mobility” (C2-3 at Higher fulcrum……. “point of maximal mobility” (C2-3 at

birth, C3-5 at 8-12yrs old to C5-6 at 12yrs old and adults)birth, C3-5 at 8-12yrs old to C5-6 at 12yrs old and adults) Weaker cervical musculatureWeaker cervical musculature Increased ligamentous laxity leading to greater mobility of Increased ligamentous laxity leading to greater mobility of

the c-spinethe c-spine Immature joints and Ossification centersImmature joints and Ossification centers Horizontal facet joints that facilitate sliding of the upper C-Horizontal facet joints that facilitate sliding of the upper C-

spinespine More susceptible to subluxation and distraction injuriesMore susceptible to subluxation and distraction injuries Spinal columns are more elastic than the spinal cord Spinal columns are more elastic than the spinal cord

(tolerating more distraction before rupture……. Thus (tolerating more distraction before rupture……. Thus leading to SCIWORAleading to SCIWORA

Key History and PE Key History and PE ComponentsComponents

HistoryHistory Cause…. MVA, Sports (Football/Diving), FallsCause…. MVA, Sports (Football/Diving), Falls Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop

Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading (Jefferson/Burst Fx)Facets), Compression or axial loading (Jefferson/Burst Fx)

Symptoms….. Numbness, tingling, or weakness during any Symptoms….. Numbness, tingling, or weakness during any time since accident even if resolvedtime since accident even if resolved

Predisposing conditions….. 15% Down’s Syndrome pts have Predisposing conditions….. 15% Down’s Syndrome pts have atlantoaxial instability, Achondroplasia (Cervicomedullary atlantoaxial instability, Achondroplasia (Cervicomedullary Junction stenosis) Junction stenosis)

Vital signsVital signs Hypotension, Bradycardia….. Can be signs of Neurogenic Hypotension, Bradycardia….. Can be signs of Neurogenic

shockshock Physical ExamPhysical Exam

Testing for motor or sensory deficits and levels if presentTesting for motor or sensory deficits and levels if present DTR’s and rectal toneDTR’s and rectal tone High index for Multisystem trauma (40% of cases have High index for Multisystem trauma (40% of cases have

associated intrabdominal injuries)associated intrabdominal injuries)

Radiologic Evaluation of Spine Radiologic Evaluation of Spine InjuriesInjuries

Are Xrays indicated?Are Xrays indicated? NEXUS Study Criteria NEXUS Study Criteria ((National Emergency X-Radiography Utilization StudyNational Emergency X-Radiography Utilization Study) )

Based on 5 low-risk criteria that allows physicians to avoid Xray Based on 5 low-risk criteria that allows physicians to avoid Xray evaluationevaluation

Must have absence of….. Midline cervical tenderness, evidence of Must have absence of….. Midline cervical tenderness, evidence of intoxication, altered level of alertness, focal neurological deficit, and a intoxication, altered level of alertness, focal neurological deficit, and a distracting painful injury.distracting painful injury.

Lateral, AP and Odontoid viewLateral, AP and Odontoid view 3 views picks up >90% of all unstable C-spine injuries3 views picks up >90% of all unstable C-spine injuries Lateral is the most important view. Lateral alone has a very high Lateral is the most important view. Lateral alone has a very high

sensitivitysensitivity Difficult to obtain odontoid views in pediatricsDifficult to obtain odontoid views in pediatrics Swimmer’s view used as adjunct to Lateral if not able to visualize Swimmer’s view used as adjunct to Lateral if not able to visualize

C7-T1 junctionC7-T1 junction Flexion-Extension viewsFlexion-Extension views

Indicated if normal 3views of the c-spine but focal neck pain Indicated if normal 3views of the c-spine but focal neck pain persists….. ie. Concerns for ligamentous injurypersists….. ie. Concerns for ligamentous injury

Only in conscious patients who can limit their neck motion Only in conscious patients who can limit their neck motion CT C-spineCT C-spine

Excellent sensitivity for identifying fractures (Sensitivity of 97%)Excellent sensitivity for identifying fractures (Sensitivity of 97%) Limited in showing ligamentous injury Limited in showing ligamentous injury

MRIMRI Indicated in any patient with neurological deficitsIndicated in any patient with neurological deficits

C-spine film evaluationC-spine film evaluation Measurable Parameters of Normal Cervical Spine Measurable Parameters of Normal Cervical Spine

RadiographsRadiographs Adequacy of C-spine viewsAdequacy of C-spine views

C1- top of T1C1- top of T1 3 views vs. Single Lateral view3 views vs. Single Lateral view

Swischuk's Lines- 4 Lordotic curves alignedSwischuk's Lines- 4 Lordotic curves aligned Predental space (5 mm or less)Predental space (5 mm or less) C2-C3 pseudosubluxation (4 to 5 mm or less)C2-C3 pseudosubluxation (4 to 5 mm or less) Retropharyngeal or Prevertebral space (1/2 to 2/3 vertebral Retropharyngeal or Prevertebral space (1/2 to 2/3 vertebral

body)body) Intervertebral disk space symmetryIntervertebral disk space symmetry

If a C-spine fracture found….. Requires radiologic evaluation If a C-spine fracture found….. Requires radiologic evaluation of entire spine.of entire spine. Approximately 10% of patients with a C-spine fracture have a Approximately 10% of patients with a C-spine fracture have a

second vertebral column fracturesecond vertebral column fracture

C-spine Lateral ViewC-spine Lateral View

C-spine AP ViewC-spine AP View

C-spine Odontoid ViewC-spine Odontoid View

C-spine Odontoid ViewC-spine Odontoid View

Swischuk’s LinesSwischuk’s Lines LINES OF LIFE: There are 4 basic parallel lines to evaluate alignment LINES OF LIFE: There are 4 basic parallel lines to evaluate alignment

that help determine c-spine injuries. that help determine c-spine injuries. Anterior vertebral body lineAnterior vertebral body line Posterior vertebral bodylinePosterior vertebral bodyline Spinal Laminar line Spinal Laminar line

Posterior spinous processPosterior spinous process

C-spine FilmsC-spine Films

Predental SpacePredental Space

Space should be no more than 5mm

Intervertebral Disk Intervertebral Disk SpacesSpaces

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

C1-C2 Rotary C1-C2 Rotary SubluxationSubluxation

Abnormal Odontoid ViewAbnormal Odontoid View

Abnormal Odontoid ViewAbnormal Odontoid View

Jefferson Fracture (C1 Burst Jefferson Fracture (C1 Burst Fracture)Fracture)

Axial loading or vertebral compressionAxial loading or vertebral compression Displaced lateral masses of C1Displaced lateral masses of C1 Predental space increasedPredental space increased Moderately unstableModerately unstable

Transverse Ligament Transverse Ligament RuptureRupture

Transverse Ligament Transverse Ligament RuptureRupture

Transverse Ligament Transverse Ligament RuptureRupture

Atlanto-occipital Atlanto-occipital DislocationDislocation

Atlanto-Occipital Atlanto-Occipital DislocationDislocation

Widening of the atlanto-occipital joint >5mmWidening of the atlanto-occipital joint >5mm Prevertebral swellingPrevertebral swelling Usually fatal Usually fatal Patients usually apneic at the scenePatients usually apneic at the scene 5X more common in children5X more common in children

Odontoid ViewOdontoid View

Type II Dens FractureType II Dens Fracture

Hangman’s FractureHangman’s Fracture

Clay-Shoveler’s FractureClay-Shoveler’s Fracture Spinous process avulsion fractureSpinous process avulsion fracture Very stable Very stable

Flexion Teardrop Flexion Teardrop FractureFracture Sudden hyperflexion with axial compressionSudden hyperflexion with axial compression

Involves disruption of all columnsInvolves disruption of all columns Usually presents with neurological impairmentUsually presents with neurological impairment

(Anterior cord syndrome)(Anterior cord syndrome) Highly unstableHighly unstable

Bilateral Facet Bilateral Facet DislocationDislocation Hyperflexion with Rotation (MVA/Diving)Hyperflexion with Rotation (MVA/Diving)

Disruption of all the spinal ligamentous columnsDisruption of all the spinal ligamentous columns Highly unstable Highly unstable Almost always quadriplegic (Poor prognosis)Almost always quadriplegic (Poor prognosis)

Chance Fracture Chance Fracture AP Thoracic SpineAP Thoracic Spine

Chance FractureChance Fracture Hyperflexion injuryHyperflexion injury Lap belt injuryLap belt injury Transverse fractures through the VBTransverse fractures through the VB 50% associated with intrabdominal 50% associated with intrabdominal

organ injuries organ injuries Posterior column disruptionPosterior column disruption

Spinal Cord Injury Without Radiographic Spinal Cord Injury Without Radiographic AbnormalityAbnormality

SCIWORASCIWORA First described in 1982First described in 1982 Defined as traumatic myelopathy in the absence of findings Defined as traumatic myelopathy in the absence of findings

on plain radiographs, flexion-extension radiographs and on plain radiographs, flexion-extension radiographs and cervical CT scan.cervical CT scan.

Almost unique to pediatrics. Occurs most often in children Almost unique to pediatrics. Occurs most often in children younger than eight years of ageyounger than eight years of age

Pediatric predominance likely related to the high elasticity Pediatric predominance likely related to the high elasticity of the spinal column in comparison to the spinal cordof the spinal column in comparison to the spinal cord

Usual mechanism is acceleration-deceleration or rotation Usual mechanism is acceleration-deceleration or rotation injuryinjury

Almost 20-50% of SCI’s in children have no radiographic Almost 20-50% of SCI’s in children have no radiographic abnormalitiesabnormalities

Almost 30-50% of patients have delayed onset of neurologic Almost 30-50% of patients have delayed onset of neurologic deficits from 30mins-4 daysdeficits from 30mins-4 days

If SCIWORA is suspected then an MRI should be doneIf SCIWORA is suspected then an MRI should be done These patients require immobilization to prevent secondary These patients require immobilization to prevent secondary

insults to the spinal cordinsults to the spinal cord

Review of Review of

Traumatic Spinal Cord Traumatic Spinal Cord SyndromesSyndromes

Motor Innervation of the Motor Innervation of the Nervous SystemNervous System

Sensory Innervation of the Sensory Innervation of the

Nervous SystemNervous System

3 Main Spinal Cord 3 Main Spinal Cord TractsTracts

Corticospinal tract carries motor fibers to the ipsilateral side of the bodyCorticospinal tract carries motor fibers to the ipsilateral side of the body Posterior columns carry fine touch, vibration, proprioception, and pressure from Posterior columns carry fine touch, vibration, proprioception, and pressure from

the ipsilateral side. the ipsilateral side. Spinothalamic tract carries pain and temperature fibers from the contralateral Spinothalamic tract carries pain and temperature fibers from the contralateral

side of the body.side of the body.

Partial Cord SyndromesPartial Cord Syndromes

Central Cord SyndromeCentral Cord Syndrome Most common of the partial cord syndromesMost common of the partial cord syndromes Hyperextension injury in athletesHyperextension injury in athletes Ligamentum flavum buckles and increases pressure on the cordLigamentum flavum buckles and increases pressure on the cord Bilateral motor paresis greater in the upper than lower Bilateral motor paresis greater in the upper than lower

extremitiesextremities Shawl distribution pain and temperature loss Shawl distribution pain and temperature loss Sparing of light touch and proprioceptionSparing of light touch and proprioception Good prognosisGood prognosis

3 Main Spinal Cord 3 Main Spinal Cord TractsTracts

Corticospinal tract carries motor fibers to the ipsilateral side of the bodyCorticospinal tract carries motor fibers to the ipsilateral side of the body Posterior columns carry fine touch, vibration, proprioception, and pressure from Posterior columns carry fine touch, vibration, proprioception, and pressure from

the ipsilateral side. the ipsilateral side. Spinothalamic tract carries pain and temperature fibers from the contralateral Spinothalamic tract carries pain and temperature fibers from the contralateral

side of the body.side of the body.

Anterior Cord SyndromeAnterior Cord Syndrome Crush Injury or compression from a hematomaCrush Injury or compression from a hematoma Compression of the Anterior Spinal arteryCompression of the Anterior Spinal artery Paraplegia below the lesion Paraplegia below the lesion Pain and temperature loss below the lesion Pain and temperature loss below the lesion Sparing of dorsal column sensation Sparing of dorsal column sensation

Brown Sequard Brown Sequard SyndromeSyndrome

Hemisection of the spinal cordHemisection of the spinal cord Usually from penetrating traumaUsually from penetrating trauma Ipsilateral plegia below the lesion Ipsilateral plegia below the lesion Ipsilateral proprioception and light touch loss Ipsilateral proprioception and light touch loss

below the lesion below the lesion Contralateral pain and temperature loss Contralateral pain and temperature loss

below the lesion below the lesion Rare injuryRare injury