1. Prof. Dr. Sadeq AL-Mukhtar
Injuries of the spine
Prof. Dr. Sadeq AL-Mukhtar

2. FUNCTION OF THE SPINE 1-Movement . 2-Transmition of weight .
3-Protection of spinal cord

3. Stability of the Spine:-
1-Interbody synarthrosis : Disc (annulus fibrosus and nucleus pulposus). 2-Posterior ligamentous complex : a-Ligamentum nuchae . b-Interspinous ligaments c-Capsules of the articular facets . d-Ligamentum flavum .

4. In cervical spine;the articulation is similar to other spines with exception of the atlas and axis. In thoracic spine stability is increased by the rib cage which forms a protective splints to this part of the spine. Therefore stability in cervical and lumber spine is NOT so great as in the thoracic spine.

5. The intervert. disc,the intervert
The intervert.disc,the intervert.canal,facet joint and interspinous ligs.must be considered as a mobile complex joints injuries of such can lead to severe and sometime permanent handicap without gross physical characteristics,such are commonly seen in motor vehicle,sports,other accidents.These are much more common than bony injuries.

6. EFFECTS OF SPINE INJURIES
1-Damage to vert.column. 2-Damage to the neural tissue; a-At the moment of injury. b-Movements may cause or aggravate the neural lesions.

7. CLASSIFICATION:
1-Stable :In which the vert.components will not be displaced by normal movements;if the neural elements are undamaged, thereis little or no risk of them becoming damaged.
2-Unstable:In which there is a significant risk of displacement and consequent damage to the neural tissues.
3-Neurological instability refers specifically to burst fracture where a neurological deficit develops when the patient is mobilized because of bone protrusions from vert.body into the spinal canal.

8. To assess stability ,the structural elements are divided into: 1-Posterior column:consistes of pedicle,facet joints,posterior bony arch,interspinous and supraspinous ligaments. 2-Middle column consist of posterior half of vert.body,posterior half of intervert.disc and posterior long.ligament. 3-anterior column:consist of anterior half of vert. body ,anterior part of intervert. disc,and ant.long.lig.

9. All fractures involving middle column and at least one other column should be regarded as UNSTABLE. Fortunately 10% of spine fractures are unstable,and <5% are associated with cord damage.

10. MECHANISMS OF INJURIES
1-Simple forced flexion with slight compression of vert. body.
2-Flexion and rotational injuries disrupting the post.long.ligament.
3-Violent vertical compression.
4-Hyperextention or retroflexion injury.

13. -High index of suspicion.
DIAGNOSIS
1-History;
-High index of suspicion.
-Every patient with blunt injury above clavical, head injury or loss of consciousness SHOULD be considered to have a cervical spine injury until proven otherwise.
-Every patient who is involved in fall from a height or a high speed deceleration accident SHOULD be considered to have thoracolumber injury. .

14. 2-Examination; Look,Feel BUT NOT MOVE Examin the head ,face neck for any bruising ,deformity,pentrating injuries. Examin the back by using LOG-ROLLED technique to avoid abnormal movements.

15. 3-Imaging;
a-Plain x-ray is mandatory for all accidents victims (cervical) who complains of neck pain ,stiffness.Also for all head injured patient ,all patients with facial injuries,patients with rib fractures,seat-belt bruising(thoracic and cervical x-ray)and thoracolumber x-ray for pelvic and or abdominal injuries.Cervical , pelvic and chest x-Ray for all unconscious patients.
b-CT-Scanning ideal structural damage to individual vert.
c-MRI for intervert.disc,lig.flavum and neural structural damage.
d-CT-myelography for dimension of spinal canal,or root avultion

16. : PRINCIPLES OF MANAGEMENTS
Follow the principles of resuscitation protocol A,B,C,D,and E in management of any patient with trauma or spinal injuries.A-AIRWAY and CERVICAL spine support.Adequat oxygenation,ventilation and circulation WILL minimized secondary spinal cord injury.
The spine must be immobilized in ALL trauma patients untill the patient has been resuscitated and other life-threatned conditions are dealt with.
Immobilization is abandoned only when spinal injuries has been excluded by clinical and radiological assessment.

17. 1-Cervical spine in-line immobilization,head and neck are supported in the neutral position. 2-Quadruple immobilization; a-Back board. b-Sand bags c-Forced head tape. d-Semi-riged collar. 3-Scoop stretcher and spinal board(for transport only) then using log-roll techniqu to transfer the patient to special bed.

18. DEFINITIVE TREATMENT :
PRINCIPLES
1-To preserve neurological functions.
2-To relieve any reversable neural compression.
3-To restore alignmeht of the spine.
4-To stabilize the spines.
5-To rehabilitate the patients.

19. So the treatment includes; 1-Patient with no bony damage and only mild soft tissue injury may be dealt with in the accident department and send home with instructions and follow up. 2-Severely injured patient should be admitted and dealt with .Special attention to prevent bed sores. 3-Stable fractures can be left as they are and treated by supporting the spine in a position that will cause no further damage 4-Unstable fractures should be held secure untill the tissues and the spine become stable,by using different methods of treatment;traction,collars,and surgery. 5-Complete neurological lesions are usually assest at time of admisson and follow up is important,frequant examination and treat accordingly 6-Different types of tractions can be used in cervical and lumbosacral region for definative treatment or prior to surgery.

20. :CONSEVATIVE SPECIFIC TREATMENT
1-cervical
a-Collar
-soft collar.
-semi-rigid
-four-poster brace(mandible,occipt,sternum,and upper thoracic spine)
b-Tongs for skeletal traction
c-Halo ring-(four pins plus ring for traction)
d-Fixation-surgical.
2-Thoracolumber;
a-Beds-Special beds designed to avoid pressure sores.
b-Brace
c-Decompression and stabilization(anterior or posterior approachs).

21. CERVICAL SPINE INJURY 1-Occipital-atlantal dislocation
It is usually fatal.
Diagnosis by lateral view x-Ray(the tip of odontoid should be no more than 5 mm in vertical alignment and 1 mm in horizontal alignment from the anterior rim of foramen magnum.
Treatment;halo ring immobilization without traction followed by posterior fusion of occiput to upper cervical spine.
2-C-1 fracture(Jeffersons fracture)
Burst fracture of the ring of atlas caused by sudden severe load on the top of the head.
Diagnosis;By open mouth view x-Ray,CT scan is helpful.
3-Odontoid fracture;Flexion injury after high -velosity accident or severe fall.
Cord injury seen in 25% of cases
Diagnosis;By x-Ray,tomogram,MRI.
Treatment;According to the type of fracture(three types).

22. 4-Fracture C2-pedicle(HANGMANS FRACTURE) Fracture of the pedicle of axis and disc c1-c2 is torn.The mechanism of fracture is extentionplus distraction.Death caused by decompression of spinal cord.unstable fracture. 5-Lower cervical spine -Wedge compression fracture. -Posterior lig. injury. -Burst fracture. -Flexion-rotation with unilateral or bilateral facet dislocation. -Tear-drop fracture. -Hyperextention injury. -Avulsion of spinous process. -Cervical disc herniation.

23. THORACIC SPINE INJURY Treatment:
Hyperflexion fracture usually wedge-compression.therib cage tends to protect all but the lower two or three.
Because of narrow spinal canal so cord damage is not uncommon and when it does occur it is usually complete.
Treatment:
Stable fracture of less than 30 degree kyphosis without neurological iniuries are managed symptomatically.If >30 degree bracing or posterior fusion.
If there is complete paraplegia with no improvement after 48 hrs conservative treatment is adequat ,bed rest for 5-6 weeks then gradual mobilization in brace.With severe kyphosis spinal fusion should be considered.
If paraplegia is partial decompression and stabilizayion through transthoracic approach.

24. THORACOLUMBER INJURY Types;
1-Minor fracture of vertebral processe and pars interarticularis.
2-Major-compression,burst fracture,and fracture-dislocation.

25. Wedge-compression fracture;
Most common vertebral fracture due to flexion injury.posterior lig.intact,the body is crushed anteriorly.If the loss of anterior vertebral height<50% is a simple type .If>50% progressive collaps may occur,and a well fitting plaster jacket is applied.

26. Thank you .