SPINAL INJURY

Spinal Injury most commonly occurs due to Road Traffic Accidents (RTAs), fall from heights, sports injuries etc. Cervical spine injuries most commonly occur as a result of whiplash injuries during an RTA or diving into a shallow swimming pool. The treatment for spinal injuries is to stabilize the fracture and remove any compression on the spinal cord. A period of neuro- rehabilitation will be required following surgery if there is a weakness of the limbs.

 

Trauma may result in injury to the spinal bone (spinal fracture) and/or injury to the spinal cord, which lies within the spinal bony canal. There are two most common spinal injuries:

1. Spinal fracture

2. Spinal cord injury

 

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SPINAL FRACTURE

Introduction

Spinal fracture is a break in one or more bones in the spinal column. These fracture may include any of the 33 bones in the spinal column. These fractures may result from trauma or other bone-weakening diseases.

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A common cause for non-traumatic spinal fractures is osteoporosis. Those with osteoporosis often sustain vertebral compression fractures — the breaking and collapsing of the bone. It is also more common for people with osteoporosis to fracture their vertebrae during a fall.

A vertebral compression fracture can result in sudden acute back pain, chronic dull pain or no pain at all.

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Trauma to the spine is often associated with other injuries. These may include fractures of the ribs or sternum and contusion of the lungs with pneumothorax in cases of thoracic spine fracture.

Fractures of the lumbo-sacral spine may be associated with fractures of the pelvis. In trauma cases, multiple spinal fractures may be seen in upto 1/3rd of cases and hence the importance of screening the whole spine in cases of injury. There may be bruising over the skin of the affected area of the spine, hence the need to undress the patient, inspect and examine the spine carefully.

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Spinal fractures can also be caused by bone weakening due to cancer which may be secondary to a tumor elsewhere (metastasis) and other chronic disorders requiring long term steroid use as in asthma, sarcoidosis, etc.

 

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Symptoms

1. Pain - Depending on the site of fracture there will be pain and tenderness at that site. Pain will be aggravated by movement of that part of the spine.

2. Weakness/Numbness of limbs - Depending on the extent of compression of the spinal cord or nerve roots there may be weakness or numbness of the limbs as well as bowel and bladder involvement in cases of severe spinal cord injury.

 

 

Treatment options

Depending on the type, location and presentation of the fracture, treatment is individualized for each patient.

1. Conservative Treatment –

   • If the vertebral fracture is found to be stable (no abnormal movement seen) with no significant spinal cord compression, a combination of rest, bracing and pain medications may be prescribed.

2. Surgery –

   • If the vertebrae are unstable and/or the fracture endangers the spinal cord or nerves, spinal decompression and stabilization (link to page 14) surgery is required.

   • In some patients, surgery is required to relieve pain and to restore the support and structural integrity required for normal spine function.

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SPINAL CORD INJURY

 

Introduction

Symptoms: Based on the site of injury patient may have varying patterns of neurological deficits.

1. Cervical injury:  weakness of all 4 limbs (quadriplegia) with / without bladder/bowel dysfunction.

2. Lumbar injury: bladder/bowel dysfunction with leg and foot weakness and sensory loss.   

3. Thoracic injury: Weakness of both lower limbs (paraplegia) with or without bladder/bowel dysfunction.

 

Investigations

1. MRI of the spine shows the spinal cord and the nerve roots arising from it, the vertebra, discs, ligaments and surrounding structures. MRI shows the integrity of the spinal cord and any damage within the cord. It will also show damage to structures around the vertebra and give an indication of the stability of the spine. This will determine the type of treatment given to the patient.

2. X-Ray of the spine shows the vertebra and there alignment. Most commonly this is done in flexion and extension to check for any instability (listhesis). This flexion and extension is not done in acute spinal injuries for fear of further damaging the cord. It is also an easy and cheap investigation for follow up.

3. CT scan of the spine is done in certain cases where, after MRI and X-ray, some more information is required by the surgeon, particularly if surgery is planned. Increasingly in trauma CT of the whole body is done as soon as the patient arrives in the emergency room. This helps pick up other injuries associated with spinal injuries, for example – head, limb, chest and abdominal injuries. This quick assessment helps the trauma team in prioritizing the treatment.

 

Treatment

1. Surgical Management – treatment is aimed towards strengthening and restoring the spinal column along with spinal decompression and stabilization (link to page 14) (using transpedicular screws, interbody cages anterior plates and other implants).

2. Rehabilitation - Following surgery, a long period of neuro- rehabilitation may be required to recover from the weakness of the limbs. Recovery of limb function may not be complete in some cases and in some cases there may be permanent complete paraplegia or quadriplegia with loss of bowel and bladder function. Therapists can teach a patient, even with severe limb weakness, to walk independently using some form of assistive technology (such as walkers, calipers, braces, exo-skeleton etc.). Bladder rehabilitation involves intermittent catheterization, preferably by the patient - especially if he has use of his hands.Chest physiotherapy and care of the skin to prevent bedsores starts while the patient is in ICU and should continue even after discharge from the hospital.