PANCE Blueprint Musculoskeletal (8%)

Trauma of the spine

Patient will present as → a 33-year-old female involved in a motor vehicle accident in which she is rear-ended in slow moving traffic at less than 10 MPH. She presents to the ER complaining of localized neck stiffness and pain. On physical exam she has paraspinal tenderness in the cervical region. She has limited motion secondary to pain. Her motor, sensory, and reflex exam are normal in her upper and lower extremities. Radiographs are obtained and show normal cervical spine AP and lateral radiographs.

All trauma patients have a cervical spine injury until proven otherwise

  • Cervical clearance can be performed with physical exam and radiographically
  • CT to bottom of first thoracic vertebra replacing conventional radiographs as initial imaging in most trauma centers
  • Removal of cervical collar WITHOUT radiographic studies is allowed if patient is awake, alert, and not intoxicated AND
    • Has no neck pain, tenderness, or neurologic deficits AND has no distracting injuries

Fractures at the level of the spinal cord (above L1/2) are much more vulnerable to neurologic injury than injuries below and require a more urgent treatment

Thoracic spine (T2-T10)

  • Fractures from T2-T10 are rare due to increased stability of thoracic spine
    • Is a vascular watershed area so vascular injury can lead to cord ischemia
    • Burst fracture
    • Osteoporotic compression fracture
    • Fracture dislocation (rare but leads to paralysis in 80%)

Thoracolumbar region (T11 to L2)

  • More commonly affected by spine trauma due to fulcrum of motion (intersection between stiff thoracic spine and increased motion of lumbar spine)
    • More than 50% of all thoracic and lumbar fractures occur in this region

Lumbar region (L3 to S1)

  • Spinal cord ends and cauda equina begins at level of L1/L2
  • Injuries below L1 have a better prognosis because the nerve roots (cauda equina and nerve roots within thecal sac) are affected as opposed to the spinal cord

Magerl classification (of thoracic spine injuries)

  • Type A
    • Compression caused by axial loading
  • Type B
    • B1: ligamentous distraction injury posterior
    • B2: osteoligamentous distraction injury posterior
  • Type C
    • Multi directional injuries, often fracture dislocations
      • Very unstable with high likelihood of neurologic injury

AO classification (of thoracolumbar spinal fracture)

  • Type A: Compression injuries
  • Type B: Distraction injuries
  • Type C: Torsional injury
Level Patient Function
C1-C3 - Ventilator dependent with limited talking. - Electric wheelchair with head or chin control
C3-C4 - Initially ventilator dependent, but can become independent - Electric wheelchair with head or chin control
C5 - Ventilator independent - Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself - Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function
C6 - C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself (wrist extension and supination intact) - Independent living; manual wheelchair with sliding board transfers, can drive a car with manual controls
C7 - Improved triceps strength - Daily use of a manual wheelchair with independent transfers
C8-T1 - Improved hand and finger strength and dexterity - Fully independent transfers
T2-T6 - Normal UE function - Improved trunk control - Wheelchair-dependent
T7-T12 - Increased abdominal muscle control - Able to perform unsupported seated activities; with extensive bracing walking may be possible
L1-L5 - Variable LE and B/B function - Assist devices and bracing may be needed
S1-S5 - Various return of B/B and sexual function - Walking with minimal or no assistance

Obtain radiographs of entire spine (concomitant spine fractures in 20%)

  • CT scan indications
    • Fracture on plain film
    • Neurologic deficit in lower extremity
    • Inadequate plain films
  • MRI useful to evaluate for
    • Injury to anterior and posterior ligament complex
    • Spinal cord compression by disk or osseous material
    • Cord edema or hemorrhage

Most thoracic and thoracolumbar fractures (burst and compression) can be treated nonoperatively when the patient is neurologically intact

  • Treat in orthosis for 6 to 12 weeks depending on degree of instability
  • Indications for surgery include progressive neurologic deficits
    • Myelomalacia seen on MRI
    • Gross spinal instability

Question 1
A 73-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have?
A
Anterior cord syndrome
Hint:
Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function.
B
Central cord syndrome
C
Brown-Séquard syndrome
Hint:
Brown-Séquard syndrome is a condition associated with hemisection or damage to one half of the spinal cord, resulting in a loss of sensations like pain, temperature, touch, as well as paralysis or loss of muscle function in some parts of the body.
D
Complete cord transection
Hint:
Complete cord transection would affect motor and sensory function distal to the lesion.
E
Cauda equina syndrome
Hint:
Cauda equina syndrome typically presents as low back pain with radiculopathy.
Question 1 Explanation: 
The central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain with radiculopathy.
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