of the Spine and Spinal Cord

Fig. 25.1

(a) Normal lateral C-spine X-ray showing anterior spinal line, posterior spinal line, and spinolaminar line. (b) C-spine X-ray after trauma. Note break in posterior spinal line indicating C4–C5 facet disruption and bony instability

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig2_HTML.png — Fig. 25.2

AP X-ray of TL spine demonstrating key parameters. Interspinous distance (*vertical arrow*), interpedicular distance (*horizontal arrow*), and vertebral height (*bracket*)

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig3_HTML.png — Fig. 25.3

Lateral X-ray after T11–T12 trauma showing kyphosis and loss of vertebral body height and facet disruption (*circle*)

Knowledge of the mechanism of injury enables further scrutiny of key areas and injury patterns:

Axial load (Fig. 25.4): burst fractures with variable involvement of all three columns
Flexion load (Fig. 25.5): anterior column compression with disruption of posterior column in tension
Extension load (Fig. 25.6): anterior column tension failure with compression of posterior column

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig4_HTML.jpg — Fig. 25.4

(a) Axial load leads to compression or burst fracture. (b) Lateral X-ray of burst fracture of L3

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig5_HTML.jpg — Fig. 25.5

(a) Flexion injury leads to compression injury of anterior elements and tension injury of posterior elements. (b) Lateral X-ray of flexion injury of C-spine

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig6_HTML.jpg — Fig. 25.6

(a) An extension load leads to anterior tension injury and posterior compression. (b) Lateral CT image of extension injury of C-spine

Instituting a protocol for evaluating these patients in the resource-poor setting is likely to be challenging, but the visiting orthopedist should make it a point to follow a consistent and thorough pattern of evaluation. At hospitals that see a fair amount of trauma, an initial evaluation of current processes is a good idea. This can be followed by an in-service for junior physicians, nurses, and radiology personnel on the implementation of a basic spine trauma screening protocol. Leaving the site with such a protocol for clinical and radiographic evaluation will go a long way toward both patient care and education.

Assessment of the Injury

Once an injury has been identified, the surgeon needs to assess its stability and, to a lesser degree, the acuity of the treatment needed. With regard to the second point, most of these patients will have had a significant delay between their injury and the time of evaluation, and it is unlikely that a progressive neurologic deficit will present itself at a point at which an urgent decompression is necessary.

The issue of stability is of paramount importance when determining a treatment plan. Distinctions should be made between acute structural instability and the potential for late structural instability, as well as between neurologically stable and unstable lesions. An instability checklist to assist with treatment algorithms is shown below. At least three should be present for the injury to be considered unstable:

Anterior elements not functional
Posterior elements not functional
Sagittal plane translation
Sagittal plane rotation
Positive stretch test (neural tension sign, radicular pain with elongation of nerve root)
Spinal cord involvement

Stability

Although there is some controversy regarding classification of spinal injuries, the three-column concept is one that all visiting orthopedists should be able to apply when evaluating a spinal injury. The spine is divided into anterior, middle, and posterior columns (Fig. 25.7). Generally, an injury involving three columns is said to be acutely unstable, and in resource-rich environments these patients will often be treated surgically. The concept of acute versus late instability becomes an issue with two-column injuries. Often the indication for stabilization of these injuries is the potential for delayed-onset or late-onset deformity. A one-column injury is unlikely to need any type of stabilization, either with an orthosis, cast, or surgery.

../images/270913_2_En_25_Chapter/270913_2_En_25_Fig7_HTML.png — Fig. 25.7

The three columns of the spinal unit

A patient who is losing neurologic function is considered to be neurologically unstable. For the vast majority of neurologically unstable spine trauma patients in resource-poor settings, there is little to be done. Axial imaging with CT and MRI, if available, can give greater detail about the area in question, leading to consideration of a surgical decompression if the resources are available. Such expensive tests are helpful only if they will alter management.

Treatment

The most common injury patterns seen and their treatments in resource-poor settings are noted in the table below. If Gardner-Wells tongs are available for reduction of cervical fracture dislocations, the sterile pins should be placed at 60 lb inches of torque just above the external auditory meatus and below the equator of the skull (Fig. 25.8). Traction up to half of the patient’s body weight is sometimes needed to achieve an awake reduction of facet dislocations, which can be difficult for both the tongs and the patient to tolerate.