30 T_h e neck and spine

• A system for evaluation of the lateral cervical sp
• A system for evaluation of the lateral cervical spine radiograph
• ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy
• ANATOMY OF THE SPINE AND SPINAL CORD Spinal column
• Atlantoaxial instability
• CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles
• CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL
• Complete versus incomplete spinal cord injury
• Computed tomography
• DIAGNOSTIC IMAGING Plain radiographs
• Dynamic imaging
• EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY
• FURTHER READING
• Fractures in patients with ankylosing spondylitis
• INJURY
• Identification of shock
• Introduction
• LEFT
• Learning objectives
• Magnetic resonance imaging
• Neurological examination
• OUTCOME
• Odontoid fractures
• PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary
• PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury
• PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary
• PATIENT ASSESSMENT Basic points
• PERTINENT HISTORY
• PHYSICAL EXAMINATION Initial assessment
• Prognosis of spinal cord injury
• RIGHT
• Regional variations
• SPECIFIC SPINAL INJURIES Upper cervical spine (sku
• SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2)
• Spinal examination
• Spinal neuroanatomy
• Spinal stability
• Subaxial cervical spine (C3–C7)
• The secondary injury
• Thoracic and thoracolumbar fractures
• cord injury

A system for evaluation of the lateral cervical sp

A system for evaluation of the lateral cervical spine radiograph

1 Assess prevertebral soft-tissue swelling ( Figure 30.14 2 Assess sagittal alignment using three imaginary lines ( Figure 30.15 ). 3 Assess for instability ( Figure 30.16 ): a 3.5 /uni00A0 mm of sagittal translation; b sagittal angulation of >11° (compared with the adja cent level). Examiner Name Signature SENSORY MOTOR KEY SENSORY POINTS KEY MUSCLES A system for evaluation of the lateral cervical spine radiograph

1 Assess prevertebral soft-tissue swelling ( Figure 30.14 2 Assess sagittal alignment using three imaginary lines ( Figure 30.15 ). 3 Assess for instability ( Figure 30.16 ): a 3.5 /uni00A0 mm of sagittal translation; b sagittal angulation of >11° (compared with the adja cent level). Examiner Name Signature SENSORY MOTOR KEY SENSORY POINTS KEY MUSCLES

A system for evaluation of the lateral cervical spine radiograph

A system for evaluation of the lateral cervical spine radiograph

1 Assess prevertebral soft-tissue swelling ( Figure 30.14 2 Assess sagittal alignment using three imaginary lines ( Figure 30.15 ). 3 Assess for instability ( Figure 30.16 ): a 3.5 /uni00A0 mm of sagittal translation; b sagittal angulation of >11° (compared with the adja cent level). Examiner Name Signature SENSORY MOTOR KEY SENSORY POINTS KEY MUSCLES

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy

The vertebral column is composed of a series of motion segments ( Figure 30.1 ). A motion segment consists of two adjacent vertebrae, their intervertebral disc and ligamentous restraints ( Figure 30.2 ).

Vertebral body Facet joints Pedicle Figure 30.1 The spinal motion segment.

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy

The vertebral column is composed of a series of motion segments ( Figure 30.1 ). A motion segment consists of two adjacent vertebrae, their intervertebral disc and ligamentous restraints ( Figure 30.2 ).

Vertebral body Facet joints Pedicle Figure 30.1 The spinal motion segment.

ANATOMY OF THE SPINE AND SPINAL CORD Spinal column anatomy

The vertebral column is composed of a series of motion segments ( Figure 30.1 ). A motion segment consists of two adjacent vertebrae, their intervertebral disc and ligamentous restraints ( Figure 30.2 ).

Vertebral body Facet joints Pedicle Figure 30.1 The spinal motion segment.

Atlantoaxial instability

Atlantoaxial instability

This is defined as non-physiological movement between C1 and C2. It can be translational or rotatory and resolves either spontaneously or with traction followed by a cervical collar. Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion ( Figure 30.26 ). Atlantoaxial instability

This is defined as non-physiological movement between C1 and C2. It can be translational or rotatory and resolves either spontaneously or with traction followed by a cervical collar. Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion ( Figure 30.26 ). Atlantoaxial instability

This is defined as non-physiological movement between C1 and C2. It can be translational or rotatory and resolves either spontaneously or with traction followed by a cervical collar. Isolated, traumatic transverse ligament rupture leading to C1/2 instability is uncommon and is treated with posterior C1/2 fusion ( Figure 30.26 ).

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles

Spinal realignment In cases of cervical spine subluxation or dislocation, skeletal traction is necessary to achieve anatomical realignment. This is done using skull tongs ( Figure 30.19 ). tion and stabilisation using internal fixation is also required ( Figure 30.20 ).

(a) (b) (d) (c) Figure 30.19 Skeletal traction using skull tongs. Figure 30.20 (a) Thoracolumbar fracture dislocation, (b) treated with open reduction and posterior /f_i xation. (c) Bifacetal cervical spine dislocation. (d) Posterior stabilisation following closed reduction.

and immobilisation of cervical fractures ( Figure 30.21 Stabilisation The indication for operative intervention is influenced by the injury pattern, level of pain, degree of instability and the pres ence of a neurological deficit. The only absolute indication for surgery in spinal trauma is deteriorating neurological function. Decompression of the neural elements Realignment of the spine and correction of the spinal deformity may achieve an indirect decompression. A direct decompression of the neural elements may also be indicated if there are bone fragments causing residual compression or a significant haematoma ( Figure 30.22 ). The timing of surgery in spinal cord trauma remains controversial. Corticosteroids Corticosteroids are no longer indicated in acute spinal cord injury because of a lack of evidence to support e ffi cacy . Steroids do have a role in non-traumatic spinal cord compression, e.g. malignant spinal cord compression. Summary box 30.5 Management of spinal trauma /uni25CF /uni25CF /uni25CF ). -

Figure 30.21 External immobilisation using a halo jacket. Neurological de /f_i cit determines management Deteriorating neurological status requires surgical intervention Corticosteroids are ineffective (b) Figure 30.22 (a) Sagittal T2-weighted magnetic resonance imaging scan showing an L1 burst fracture and neural compression; (b) treated with combined anterior and posterior surgery.

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles

Spinal realignment In cases of cervical spine subluxation or dislocation, skeletal traction is necessary to achieve anatomical realignment. This is done using skull tongs ( Figure 30.19 ). tion and stabilisation using internal fixation is also required ( Figure 30.20 ).

(a) (b) (d) (c) Figure 30.19 Skeletal traction using skull tongs. Figure 30.20 (a) Thoracolumbar fracture dislocation, (b) treated with open reduction and posterior /f_i xation. (c) Bifacetal cervical spine dislocation. (d) Posterior stabilisation following closed reduction.

and immobilisation of cervical fractures ( Figure 30.21 Stabilisation The indication for operative intervention is influenced by the injury pattern, level of pain, degree of instability and the pres ence of a neurological deficit. The only absolute indication for surgery in spinal trauma is deteriorating neurological function. Decompression of the neural elements Realignment of the spine and correction of the spinal deformity may achieve an indirect decompression. A direct decompression of the neural elements may also be indicated if there are bone fragments causing residual compression or a significant haematoma ( Figure 30.22 ). The timing of surgery in spinal cord trauma remains controversial. Corticosteroids Corticosteroids are no longer indicated in acute spinal cord injury because of a lack of evidence to support e ffi cacy . Steroids do have a role in non-traumatic spinal cord compression, e.g. malignant spinal cord compression. Summary box 30.5 Management of spinal trauma /uni25CF /uni25CF /uni25CF ). -

Figure 30.21 External immobilisation using a halo jacket. Neurological de /f_i cit determines management Deteriorating neurological status requires surgical intervention Corticosteroids are ineffective (b) Figure 30.22 (a) Sagittal T2-weighted magnetic resonance imaging scan showing an L1 burst fracture and neural compression; (b) treated with combined anterior and posterior surgery.

CLASSIFICATION AND MANAGEMENT OF SPINAL AND SPINAL CORD INJURIES Basic management principles

Spinal realignment In cases of cervical spine subluxation or dislocation, skeletal traction is necessary to achieve anatomical realignment. This is done using skull tongs ( Figure 30.19 ). tion and stabilisation using internal fixation is also required ( Figure 30.20 ).

(a) (b) (d) (c) Figure 30.19 Skeletal traction using skull tongs. Figure 30.20 (a) Thoracolumbar fracture dislocation, (b) treated with open reduction and posterior /f_i xation. (c) Bifacetal cervical spine dislocation. (d) Posterior stabilisation following closed reduction.

and immobilisation of cervical fractures ( Figure 30.21 Stabilisation The indication for operative intervention is influenced by the injury pattern, level of pain, degree of instability and the pres ence of a neurological deficit. The only absolute indication for surgery in spinal trauma is deteriorating neurological function. Decompression of the neural elements Realignment of the spine and correction of the spinal deformity may achieve an indirect decompression. A direct decompression of the neural elements may also be indicated if there are bone fragments causing residual compression or a significant haematoma ( Figure 30.22 ). The timing of surgery in spinal cord trauma remains controversial. Corticosteroids Corticosteroids are no longer indicated in acute spinal cord injury because of a lack of evidence to support e ffi cacy . Steroids do have a role in non-traumatic spinal cord compression, e.g. malignant spinal cord compression. Summary box 30.5 Management of spinal trauma /uni25CF /uni25CF /uni25CF ). -

Figure 30.21 External immobilisation using a halo jacket. Neurological de /f_i cit determines management Deteriorating neurological status requires surgical intervention Corticosteroids are ineffective (b) Figure 30.22 (a) Sagittal T2-weighted magnetic resonance imaging scan showing an L1 burst fracture and neural compression; (b) treated with combined anterior and posterior surgery.

Complete versus incomplete spinal cord injury

Complete versus incomplete spinal cord injury

A spinal cord injury is incomplete when there is preservation of perianal sensation. Types of incomplete spinal cord injury There are several types of incomplete spinal cord injuries. These include: /uni25CF central cord syndrome; /uni25CF Brown-Séquard syndrome (hemisection); /uni25CF anterior spinal syndrome; /uni25CF posterior cord syndrome; /uni25CF cauda equina syndrome. Charles Edward Brown-Séquard , 1817–1894, physiologist and neurologist who held a number of academic posts, among them Physician, the National Hos pital for Nervous Diseases, London, UK (1860–1864), Professor of Medicine at Harvard University , Boston, MA, USA (1864–1878), and at the Collège de France, Paris, France (1878–1894). He described his syndrome in 1851.

TABLE 30.1 Expected functional outcome versus level of cervical spinal cord injury. Level of injury Functional goal C3–C4 Power wheelchair with mouth or chin control. Verbalise care, communicate through adaptive equipment. May be ventilator dependent C5 Power wheelchair, dress upper body, self-feed with aids, wash face with assistance C6 Propel power wheelchair, possibly push manual wheelchair, transfer with assistance, dress upper body (lower body with assistance), self-groom with aids, bladder/bowel care with assistance, self-feed with splints, able to drive C7 Manual wheelchair, independent transfer, dressing (with aids), feeding, bathing, self-care. Bladder and bowel care with assistance C8–T4 Independent with most activities of daily living, and bowel and bladder care T5–T12 As above but with more ease. Independent with all self-care L1–L5 Independent. Walk with short or long leg braces S1–S5 Independent, able to walk if able to push off (S1) (may need brace). Bladder, bowel and sexual function may remain compromised TABLE 30.2 Life expectancy (years) post injury by severity of injury and age at injury. Age at injury No SCI Motor functional at any level a For people who survive the /f_i rst 24 hours 20 58.4 52.8 40 39.5 34.3 60 22.2 17.9 b For people surviving at least 1 year post injury 20 58.4 53.3 40 39.5 34.8 60 22.2 18.3 SCI, spinal cord injury.

Complete versus incomplete spinal cord injury

A spinal cord injury is incomplete when there is preservation of perianal sensation. Types of incomplete spinal cord injury There are several types of incomplete spinal cord injuries. These include: /uni25CF central cord syndrome; /uni25CF Brown-Séquard syndrome (hemisection); /uni25CF anterior spinal syndrome; /uni25CF posterior cord syndrome; /uni25CF cauda equina syndrome. Charles Edward Brown-Séquard , 1817–1894, physiologist and neurologist who held a number of academic posts, among them Physician, the National Hos pital for Nervous Diseases, London, UK (1860–1864), Professor of Medicine at Harvard University , Boston, MA, USA (1864–1878), and at the Collège de France, Paris, France (1878–1894). He described his syndrome in 1851.

TABLE 30.1 Expected functional outcome versus level of cervical spinal cord injury. Level of injury Functional goal C3–C4 Power wheelchair with mouth or chin control. Verbalise care, communicate through adaptive equipment. May be ventilator dependent C5 Power wheelchair, dress upper body, self-feed with aids, wash face with assistance C6 Propel power wheelchair, possibly push manual wheelchair, transfer with assistance, dress upper body (lower body with assistance), self-groom with aids, bladder/bowel care with assistance, self-feed with splints, able to drive C7 Manual wheelchair, independent transfer, dressing (with aids), feeding, bathing, self-care. Bladder and bowel care with assistance C8–T4 Independent with most activities of daily living, and bowel and bladder care T5–T12 As above but with more ease. Independent with all self-care L1–L5 Independent. Walk with short or long leg braces S1–S5 Independent, able to walk if able to push off (S1) (may need brace). Bladder, bowel and sexual function may remain compromised TABLE 30.2 Life expectancy (years) post injury by severity of injury and age at injury. Age at injury No SCI Motor functional at any level a For people who survive the /f_i rst 24 hours 20 58.4 52.8 40 39.5 34.3 60 22.2 17.9 b For people surviving at least 1 year post injury 20 58.4 53.3 40 39.5 34.8 60 22.2 18.3 SCI, spinal cord injury.

Complete versus incomplete spinal cord injury

A spinal cord injury is incomplete when there is preservation of perianal sensation. Types of incomplete spinal cord injury There are several types of incomplete spinal cord injuries. These include: /uni25CF central cord syndrome; /uni25CF Brown-Séquard syndrome (hemisection); /uni25CF anterior spinal syndrome; /uni25CF posterior cord syndrome; /uni25CF cauda equina syndrome. Charles Edward Brown-Séquard , 1817–1894, physiologist and neurologist who held a number of academic posts, among them Physician, the National Hos pital for Nervous Diseases, London, UK (1860–1864), Professor of Medicine at Harvard University , Boston, MA, USA (1864–1878), and at the Collège de France, Paris, France (1878–1894). He described his syndrome in 1851.

TABLE 30.1 Expected functional outcome versus level of cervical spinal cord injury. Level of injury Functional goal C3–C4 Power wheelchair with mouth or chin control. Verbalise care, communicate through adaptive equipment. May be ventilator dependent C5 Power wheelchair, dress upper body, self-feed with aids, wash face with assistance C6 Propel power wheelchair, possibly push manual wheelchair, transfer with assistance, dress upper body (lower body with assistance), self-groom with aids, bladder/bowel care with assistance, self-feed with splints, able to drive C7 Manual wheelchair, independent transfer, dressing (with aids), feeding, bathing, self-care. Bladder and bowel care with assistance C8–T4 Independent with most activities of daily living, and bowel and bladder care T5–T12 As above but with more ease. Independent with all self-care L1–L5 Independent. Walk with short or long leg braces S1–S5 Independent, able to walk if able to push off (S1) (may need brace). Bladder, bowel and sexual function may remain compromised TABLE 30.2 Life expectancy (years) post injury by severity of injury and age at injury. Age at injury No SCI Motor functional at any level a For people who survive the /f_i rst 24 hours 20 58.4 52.8 40 39.5 34.3 60 22.2 17.9 b For people surviving at least 1 year post injury 20 58.4 53.3 40 39.5 34.8 60 22.2 18.3 SCI, spinal cord injury.

Computed tomography

Computed tomography

Computed tomography (CT) scanning with two-dimensional reconstruction remains the gold standard in spinal trauma and is indicated for patients with suspected or visible injuries on plain radiographs ( Figure 30.17 ). Patients undergoing a head CT scan for closed head injury should also have a cervical screening CT . Often CT scans of the chest and abdomen are performed as part of the assessment of polytrauma patients and will usually include the spine.

Figure 30.17 Axial computed tomography demonstrating a thoraco

lumbar fracture dislocation.

Computed tomography

Computed tomography (CT) scanning with two-dimensional reconstruction remains the gold standard in spinal trauma and is indicated for patients with suspected or visible injuries on plain radiographs ( Figure 30.17 ). Patients undergoing a head CT scan for closed head injury should also have a cervical screening CT . Often CT scans of the chest and abdomen are performed as part of the assessment of polytrauma patients and will usually include the spine.

Figure 30.17 Axial computed tomography demonstrating a thoraco

lumbar fracture dislocation.

Computed tomography

Computed tomography (CT) scanning with two-dimensional reconstruction remains the gold standard in spinal trauma and is indicated for patients with suspected or visible injuries on plain radiographs ( Figure 30.17 ). Patients undergoing a head CT scan for closed head injury should also have a cervical screening CT . Often CT scans of the chest and abdomen are performed as part of the assessment of polytrauma patients and will usually include the spine.

Figure 30.17 Axial computed tomography demonstrating a thoraco

lumbar fracture dislocation.

DIAGNOSTIC IMAGING Plain radiographs

DIAGNOSTIC IMAGING Plain radiographs

A full cervical spine series includes anteroposterior and lateral radiographs of the whole cervical spine, and open mouth views. Clear visualisation of the cervicothoracic junction is essential in all cases of suspected spinal injury , as this is a common site for injury and often not seen on a plain radiograph. If a spinal fracture is identified then further imaging of the whole spine is required because there is a 15% incidence of a further spinal fracture. DIAGNOSTIC IMAGING Plain radiographs

A full cervical spine series includes anteroposterior and lateral radiographs of the whole cervical spine, and open mouth views. Clear visualisation of the cervicothoracic junction is essential in all cases of suspected spinal injury , as this is a common site for injury and often not seen on a plain radiograph. If a spinal fracture is identified then further imaging of the whole spine is required because there is a 15% incidence of a further spinal fracture. DIAGNOSTIC IMAGING Plain radiographs

A full cervical spine series includes anteroposterior and lateral radiographs of the whole cervical spine, and open mouth views. Clear visualisation of the cervicothoracic junction is essential in all cases of suspected spinal injury , as this is a common site for injury and often not seen on a plain radiograph. If a spinal fracture is identified then further imaging of the whole spine is required because there is a 15% incidence of a further spinal fracture.

Dynamic imaging

Dynamic imaging

Lateral flexion–extension radiographs of the cervical spine should not be undertaken acutely , although they can have a role in assessing spinal stability in the longer term.

Figure 30.18 Sagittal T2-weighted magnetic resonance imaging scan demonstrating a cervical spine subluxation and spinal cord contusion.

Diagnostic imaging of spinal injuries /uni25CF /uni25CF

Clear visualisation of the cervicothoracic junction is mandatory Plain cervical spine radiographs fail to identity 15% of injuries

Dynamic imaging

Lateral flexion–extension radiographs of the cervical spine should not be undertaken acutely , although they can have a role in assessing spinal stability in the longer term.

Figure 30.18 Sagittal T2-weighted magnetic resonance imaging scan demonstrating a cervical spine subluxation and spinal cord contusion.

Diagnostic imaging of spinal injuries /uni25CF /uni25CF

Clear visualisation of the cervicothoracic junction is mandatory Plain cervical spine radiographs fail to identity 15% of injuries

Dynamic imaging

Lateral flexion–extension radiographs of the cervical spine should not be undertaken acutely , although they can have a role in assessing spinal stability in the longer term.

Figure 30.18 Sagittal T2-weighted magnetic resonance imaging scan demonstrating a cervical spine subluxation and spinal cord contusion.

Diagnostic imaging of spinal injuries /uni25CF /uni25CF

Clear visualisation of the cervicothoracic junction is mandatory Plain cervical spine radiographs fail to identity 15% of injuries

EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY

EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY

The development of specialised spinal cord injury centres has dramatically improved the survival rates, health and functional outcomes of individuals with spinal cord injury . The first spinal cord injury centre was established in the USA in 1936 by Dr Donald Munro. In 1944 The National Spinal Injuries Centre was established at Stoke Mandeville, UK, by Sir Ludwig Guttmann. Summary box 30.8 Spinal cord injury /uni25CF /uni25CF

The incidence of spinal cord injury remains constant The outcome is improved in regional/national spinal cord injury centres

EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY

The development of specialised spinal cord injury centres has dramatically improved the survival rates, health and functional outcomes of individuals with spinal cord injury . The first spinal cord injury centre was established in the USA in 1936 by Dr Donald Munro. In 1944 The National Spinal Injuries Centre was established at Stoke Mandeville, UK, by Sir Ludwig Guttmann. Summary box 30.8 Spinal cord injury /uni25CF /uni25CF

The incidence of spinal cord injury remains constant The outcome is improved in regional/national spinal cord injury centres

EVOLUTION OF THE MANAGEMENT OF SPINAL CORD INJURY

The development of specialised spinal cord injury centres has dramatically improved the survival rates, health and functional outcomes of individuals with spinal cord injury . The first spinal cord injury centre was established in the USA in 1936 by Dr Donald Munro. In 1944 The National Spinal Injuries Centre was established at Stoke Mandeville, UK, by Sir Ludwig Guttmann. Summary box 30.8 Spinal cord injury /uni25CF /uni25CF

The incidence of spinal cord injury remains constant The outcome is improved in regional/national spinal cord injury centres

FURTHER READING

FURTHER READING

American Spinal Injury Association. International standards for neurological classification of SCI (ISNCSCI) worksheet . Available from https://asia-spinalinjury .org/international-standards-neurological - classification-sci-isncsci-worksheet/ (accessed July 2022). Bridwell KH, DeWald RL (eds). The textbook of spinal surgery , 4th edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2020. British Orthopaedic Association. British Orthopaedic Association standards for trauma: the management of traumatic spinal cord injury . London: British Orthopaedic Association, 2014. Cotler JM, Simson MJ, An HS et al . (eds). Surgery of spinal trauma . Philadelphia, PA: Lippincott Williams and Wilkins, 2000. Denis F . The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (8): 817–31. Dimar JR. Early versus late stabilisation of the spine in the polytrauma patient. Spine 2010; 35 (21S): S187–92. Fehlings MG. Essentials of spinal cord injury. Basic research to clinical practice . Stuttgart: Thieme, 2013. Fehlings MG, Tetreault LA, Wilson JR et al . A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017; 7 (3 Suppl): 84S–94S. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management . NICE Guideline NG41. London: NICE, 2016. Available from https://www .nice.org.uk/guidance/ ng41 . Vaccaro AR, Andersson G. Spine trauma focus edition. Spine 2006; 31 (11S): S1–104. FURTHER READING

American Spinal Injury Association. International standards for neurological classification of SCI (ISNCSCI) worksheet . Available from https://asia-spinalinjury .org/international-standards-neurological - classification-sci-isncsci-worksheet/ (accessed July 2022). Bridwell KH, DeWald RL (eds). The textbook of spinal surgery , 4th edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2020. British Orthopaedic Association. British Orthopaedic Association standards for trauma: the management of traumatic spinal cord injury . London: British Orthopaedic Association, 2014. Cotler JM, Simson MJ, An HS et al . (eds). Surgery of spinal trauma . Philadelphia, PA: Lippincott Williams and Wilkins, 2000. Denis F . The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (8): 817–31. Dimar JR. Early versus late stabilisation of the spine in the polytrauma patient. Spine 2010; 35 (21S): S187–92. Fehlings MG. Essentials of spinal cord injury. Basic research to clinical practice . Stuttgart: Thieme, 2013. Fehlings MG, Tetreault LA, Wilson JR et al . A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017; 7 (3 Suppl): 84S–94S. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management . NICE Guideline NG41. London: NICE, 2016. Available from https://www .nice.org.uk/guidance/ ng41 . Vaccaro AR, Andersson G. Spine trauma focus edition. Spine 2006; 31 (11S): S1–104. FURTHER READING

American Spinal Injury Association. International standards for neurological classification of SCI (ISNCSCI) worksheet . Available from https://asia-spinalinjury .org/international-standards-neurological - classification-sci-isncsci-worksheet/ (accessed July 2022). Bridwell KH, DeWald RL (eds). The textbook of spinal surgery , 4th edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2020. British Orthopaedic Association. British Orthopaedic Association standards for trauma: the management of traumatic spinal cord injury . London: British Orthopaedic Association, 2014. Cotler JM, Simson MJ, An HS et al . (eds). Surgery of spinal trauma . Philadelphia, PA: Lippincott Williams and Wilkins, 2000. Denis F . The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 1983; 8 (8): 817–31. Dimar JR. Early versus late stabilisation of the spine in the polytrauma patient. Spine 2010; 35 (21S): S187–92. Fehlings MG. Essentials of spinal cord injury. Basic research to clinical practice . Stuttgart: Thieme, 2013. Fehlings MG, Tetreault LA, Wilson JR et al . A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017; 7 (3 Suppl): 84S–94S. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management . NICE Guideline NG41. London: NICE, 2016. Available from https://www .nice.org.uk/guidance/ ng41 . Vaccaro AR, Andersson G. Spine trauma focus edition. Spine 2006; 31 (11S): S1–104.

Fractures in patients with ankylosing spondylitis

Fractures in patients with ankylosing spondylitis

Ankylosing spondylitis is a seronegative inflammatory disorder that causes autofusion of the spine. These patients have a higher risk of spinal fractures and spinal cord injury than the normal population. Senior advice should be obtained, because application of a cervical collar may be contraindicated, and patients should be managed instead in a position of comfort. Surgical stabilisation is commonly indicated. Summary box 30.6 Cervical spine injuries /uni25CF /uni25CF

Figure 30.31 C5/6 bifacetal dislocation (arrows). The majority of upper cervical spinal injuries are treated non- operatively Spinal cord injury is more commonly associated with subaxial cervical spinal injuries

Fractures in patients with ankylosing spondylitis

Ankylosing spondylitis is a seronegative inflammatory disorder that causes autofusion of the spine. These patients have a higher risk of spinal fractures and spinal cord injury than the normal population. Senior advice should be obtained, because application of a cervical collar may be contraindicated, and patients should be managed instead in a position of comfort. Surgical stabilisation is commonly indicated. Summary box 30.6 Cervical spine injuries /uni25CF /uni25CF

Figure 30.31 C5/6 bifacetal dislocation (arrows). The majority of upper cervical spinal injuries are treated non- operatively Spinal cord injury is more commonly associated with subaxial cervical spinal injuries

Fractures in patients with ankylosing spondylitis

Ankylosing spondylitis is a seronegative inflammatory disorder that causes autofusion of the spine. These patients have a higher risk of spinal fractures and spinal cord injury than the normal population. Senior advice should be obtained, because application of a cervical collar may be contraindicated, and patients should be managed instead in a position of comfort. Surgical stabilisation is commonly indicated. Summary box 30.6 Cervical spine injuries /uni25CF /uni25CF

Figure 30.31 C5/6 bifacetal dislocation (arrows). The majority of upper cervical spinal injuries are treated non- operatively Spinal cord injury is more commonly associated with subaxial cervical spinal injuries

INJURY

INJURY

The incidence and causation of spinal cord injury vary globally and reflect the demographics and industrialisation of society . Every year, around the world, between 250 /uni00A0 000 and 500 /uni00A0 000 people su ff er a spinal cord injury according to the World Health Organization in 2013. Road tra ffi c accidents remain the leading cause of spinal cord injuries worldwide. Men in the third decade of life are the most likely group to sustain serious spinal cord injury . INJURY

The incidence and causation of spinal cord injury vary globally and reflect the demographics and industrialisation of society . Every year, around the world, between 250 /uni00A0 000 and 500 /uni00A0 000 people su ff er a spinal cord injury according to the World Health Organization in 2013. Road tra ffi c accidents remain the leading cause of spinal cord injuries worldwide. Men in the third decade of life are the most likely group to sustain serious spinal cord injury . INJURY

The incidence and causation of spinal cord injury vary globally and reflect the demographics and industrialisation of society . Every year, around the world, between 250 /uni00A0 000 and 500 /uni00A0 000 people su ff er a spinal cord injury according to the World Health Organization in 2013. Road tra ffi c accidents remain the leading cause of spinal cord injuries worldwide. Men in the third decade of life are the most likely group to sustain serious spinal cord injury .

Identification of shock

Identification of shock

Three categories of shock may occur in spinal trauma /uni25CF Hypovolaemic shock . Hypotension with tachycardia and cold clammy peripheries. This is most often due to haemorrhage. It should be treated with appropriate resus - citation. /uni25CF Neurogenic shock . This presents with hypotension, a normal heart rate or bradycardia and warm peripheries. This is due to unopposed vagal tone resulting from cervical spinal cord injury at or above the level of sympathetic out - flow (T5). It should be treated with inotropic support, and care should be taken to avoid fluid overload. /uni25CF Spinal shock . Spinal shock is a temporary physiological disorganisation of spinal cord function that starts within minutes following the injury . The length of e ff ect is vari - able, but it can last 6 weeks or longer. It is characterised by paralysis, decreased tone and hyporeflexia. Once it has re - solved the bulbocavernosus reflex ( Figure 30.39 ) r eturns. -

Figure 30.39 The bulbocavernosus re /f_l ex (this can be elicited in females by traction on the Foley catheter).

The level of neurological injury is simply the most caudal neurological level with normal neurological function. Identification of shock

Three categories of shock may occur in spinal trauma /uni25CF Hypovolaemic shock . Hypotension with tachycardia and cold clammy peripheries. This is most often due to haemorrhage. It should be treated with appropriate resus - citation. /uni25CF Neurogenic shock . This presents with hypotension, a normal heart rate or bradycardia and warm peripheries. This is due to unopposed vagal tone resulting from cervical spinal cord injury at or above the level of sympathetic out - flow (T5). It should be treated with inotropic support, and care should be taken to avoid fluid overload. /uni25CF Spinal shock . Spinal shock is a temporary physiological disorganisation of spinal cord function that starts within minutes following the injury . The length of e ff ect is vari - able, but it can last 6 weeks or longer. It is characterised by paralysis, decreased tone and hyporeflexia. Once it has re - solved the bulbocavernosus reflex ( Figure 30.39 ) r eturns. -

Figure 30.39 The bulbocavernosus re /f_l ex (this can be elicited in females by traction on the Foley catheter).

The level of neurological injury is simply the most caudal neurological level with normal neurological function. Identification of shock

Three categories of shock may occur in spinal trauma /uni25CF Hypovolaemic shock . Hypotension with tachycardia and cold clammy peripheries. This is most often due to haemorrhage. It should be treated with appropriate resus - citation. /uni25CF Neurogenic shock . This presents with hypotension, a normal heart rate or bradycardia and warm peripheries. This is due to unopposed vagal tone resulting from cervical spinal cord injury at or above the level of sympathetic out - flow (T5). It should be treated with inotropic support, and care should be taken to avoid fluid overload. /uni25CF Spinal shock . Spinal shock is a temporary physiological disorganisation of spinal cord function that starts within minutes following the injury . The length of e ff ect is vari - able, but it can last 6 weeks or longer. It is characterised by paralysis, decreased tone and hyporeflexia. Once it has re - solved the bulbocavernosus reflex ( Figure 30.39 ) r eturns. -

Figure 30.39 The bulbocavernosus re /f_l ex (this can be elicited in females by traction on the Foley catheter).

The level of neurological injury is simply the most caudal neurological level with normal neurological function.

Introduction

Introduction

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LEFT

LEFT

Light Touch (LTL) Pin Prick (PPL) C2 C2 C3 C2 C4 C3 Elbow flexors C5 C4 C4 UEL Wrist extensors C6 T2 (Upper Extremity Left) T3 Elbow extensors C7 T4 Finger flexors C8 T5 T6 Finger abductors (little finger) T1 T7 T2 C8 T8 MOTOR C7 T9 T3 (SCORING ON REVERSE SIDE) T10 T4 0 = T otal paralysis T11 1 = Palpable or visible contraction T5 2 = Active movement, gravity eliminated T12 3 = Active movement, against gravity T6 L1 4 = Active movement, against some resistance Palm T7 5 = Active movement, against full resistance NT = Not testable T8 0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present Key Sensory T9 L2 Points S4-5 SENSORY T10 (SCORING ON REVERSE SIDE) T11 L 0 = Absent NT = Not testable 1 = Altered 0*, 1*, NT* = Non-SCI T12 L3 2 = Normal condition present L1 Hip flexors L2 Knee extensors L3 LEL L4 Ankle dorsiflexors L4 (Lower Extremity Left) L5 Long toe extensors L5 Ankle plantar flexors S1 S2 S3 (DAP) Deep Anal Pressure S4-5 (Yes/No) LEFT TOTALS (MAXIMUM) (56) (56) (50) SENSORY SUBSCORES LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL MAX MAX (112) (56) (50) (56) (56) (56) (112) (In injuries with absent motor OR sensory function in S4-5 only) R L 4. COMPLETE OR INCOMPLETE? 6. ZONE OF PARTIAL SENSORY Incomplete = Any sensory or motor function in S4-5 PRESERVATION MOTOR 5. ASIA IMPAIRMENT SCALE (AIS) Most caudal levels with any innervation REV 04/ 19 ). -

, revised 2019; Richmond, VA.) Figure 30.14 Large prevertebral haematoma (arrows).

c b a Figure 30.15 The anterior (a) , posterior (b) and spinolaminar are useful in identifying anterior translation on lateral radiographs of the neck. Figure 30.16 Lateral cervical spine radiograph showing obvious spinal instability with marked sagittal angulation and translation. This patient walked into the outpatient department.

LEFT

Light Touch (LTL) Pin Prick (PPL) C2 C2 C3 C2 C4 C3 Elbow flexors C5 C4 C4 UEL Wrist extensors C6 T2 (Upper Extremity Left) T3 Elbow extensors C7 T4 Finger flexors C8 T5 T6 Finger abductors (little finger) T1 T7 T2 C8 T8 MOTOR C7 T9 T3 (SCORING ON REVERSE SIDE) T10 T4 0 = T otal paralysis T11 1 = Palpable or visible contraction T5 2 = Active movement, gravity eliminated T12 3 = Active movement, against gravity T6 L1 4 = Active movement, against some resistance Palm T7 5 = Active movement, against full resistance NT = Not testable T8 0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present Key Sensory T9 L2 Points S4-5 SENSORY T10 (SCORING ON REVERSE SIDE) T11 L 0 = Absent NT = Not testable 1 = Altered 0*, 1*, NT* = Non-SCI T12 L3 2 = Normal condition present L1 Hip flexors L2 Knee extensors L3 LEL L4 Ankle dorsiflexors L4 (Lower Extremity Left) L5 Long toe extensors L5 Ankle plantar flexors S1 S2 S3 (DAP) Deep Anal Pressure S4-5 (Yes/No) LEFT TOTALS (MAXIMUM) (56) (56) (50) SENSORY SUBSCORES LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL MAX MAX (112) (56) (50) (56) (56) (56) (112) (In injuries with absent motor OR sensory function in S4-5 only) R L 4. COMPLETE OR INCOMPLETE? 6. ZONE OF PARTIAL SENSORY Incomplete = Any sensory or motor function in S4-5 PRESERVATION MOTOR 5. ASIA IMPAIRMENT SCALE (AIS) Most caudal levels with any innervation REV 04/ 19 ). -

, revised 2019; Richmond, VA.) Figure 30.14 Large prevertebral haematoma (arrows).

c b a Figure 30.15 The anterior (a) , posterior (b) and spinolaminar are useful in identifying anterior translation on lateral radiographs of the neck. Figure 30.16 Lateral cervical spine radiograph showing obvious spinal instability with marked sagittal angulation and translation. This patient walked into the outpatient department.

LEFT

Light Touch (LTL) Pin Prick (PPL) C2 C2 C3 C2 C4 C3 Elbow flexors C5 C4 C4 UEL Wrist extensors C6 T2 (Upper Extremity Left) T3 Elbow extensors C7 T4 Finger flexors C8 T5 T6 Finger abductors (little finger) T1 T7 T2 C8 T8 MOTOR C7 T9 T3 (SCORING ON REVERSE SIDE) T10 T4 0 = T otal paralysis T11 1 = Palpable or visible contraction T5 2 = Active movement, gravity eliminated T12 3 = Active movement, against gravity T6 L1 4 = Active movement, against some resistance Palm T7 5 = Active movement, against full resistance NT = Not testable T8 0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present Key Sensory T9 L2 Points S4-5 SENSORY T10 (SCORING ON REVERSE SIDE) T11 L 0 = Absent NT = Not testable 1 = Altered 0*, 1*, NT* = Non-SCI T12 L3 2 = Normal condition present L1 Hip flexors L2 Knee extensors L3 LEL L4 Ankle dorsiflexors L4 (Lower Extremity Left) L5 Long toe extensors L5 Ankle plantar flexors S1 S2 S3 (DAP) Deep Anal Pressure S4-5 (Yes/No) LEFT TOTALS (MAXIMUM) (56) (56) (50) SENSORY SUBSCORES LTR + LTL = LT TOTAL PPR + PPL = PP TOTAL MAX MAX (112) (56) (50) (56) (56) (56) (112) (In injuries with absent motor OR sensory function in S4-5 only) R L 4. COMPLETE OR INCOMPLETE? 6. ZONE OF PARTIAL SENSORY Incomplete = Any sensory or motor function in S4-5 PRESERVATION MOTOR 5. ASIA IMPAIRMENT SCALE (AIS) Most caudal levels with any innervation REV 04/ 19 ). -

, revised 2019; Richmond, VA.) Figure 30.14 Large prevertebral haematoma (arrows).

c b a Figure 30.15 The anterior (a) , posterior (b) and spinolaminar are useful in identifying anterior translation on lateral radiographs of the neck. Figure 30.16 Lateral cervical spine radiograph showing obvious spinal instability with marked sagittal angulation and translation. This patient walked into the outpatient department.

Learning objectives

Learning objectives

To be familiar with: The accurate assessment of spinal trauma • The basic management of spinal trauma and the major • pitfalls Learning objectives

To be familiar with: The accurate assessment of spinal trauma • The basic management of spinal trauma and the major • pitfalls Learning objectives

To be familiar with: The accurate assessment of spinal trauma • The basic management of spinal trauma and the major • pitfalls

Magnetic resonance imaging

Magnetic resonance imaging

MRI is indicated in all patients with neurological deficit and where assessment of ligamentous structures is important ( Figure 30.18 ).

(c) lines

Magnetic resonance imaging

MRI is indicated in all patients with neurological deficit and where assessment of ligamentous structures is important ( Figure 30.18 ).

(c) lines

Magnetic resonance imaging

MRI is indicated in all patients with neurological deficit and where assessment of ligamentous structures is important ( Figure 30.18 ).

(c) lines

Neurological examination

Neurological examination

The American Spinal Injury Association (ASIA) neurological evaluation system ( Figure 30.13 ) is an internationally accepted method of neurological evaluation. Motor function is assessed using the Medical Research Council (MRC) grading system (0–5) in key muscle groups Hans Ludwig Frankel , b. 1932, Clinical Director, The National Spinal Injuries Centre, Stoke Mandeville, UK. ( Figure 30.13 ). A motor score can then be calculated (max - imum 100). Sensory function (light touch and pin prick) is assessed using the dermatomal map ( Figure 30.13 ). A total sensory score is then calculated. Rectal examination is performed to assess anal tone, volun - tary anal contraction and perianal sensa tion. Level of neurological impairment The extent of spinal cord injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification): /uni25CF A: complete spinal cord injury; /uni25CF B: sensation present, motor absent; /uni25CF C: sensation present, motor present but not useful (MRC grade <3/5); /uni25CF D: sensation present, motor useful (MRC grade ≥ 3/5); - /uni25CF E: normal function. Summary box 30.3 Physical examination /uni25CF /uni25CF

Figure 30.12 Spinal log roll. The ASIA neurological scoring system should be used Functional motor power is MRC grade 3/5 or higher

CLASSIFICATION OF SPINAL CORD INJURY ( ISNCSCI ) MOTOR KEY MUSCLES Neurological examination

The American Spinal Injury Association (ASIA) neurological evaluation system ( Figure 30.13 ) is an internationally accepted method of neurological evaluation. Motor function is assessed using the Medical Research Council (MRC) grading system (0–5) in key muscle groups Hans Ludwig Frankel , b. 1932, Clinical Director, The National Spinal Injuries Centre, Stoke Mandeville, UK. ( Figure 30.13 ). A motor score can then be calculated (max - imum 100). Sensory function (light touch and pin prick) is assessed using the dermatomal map ( Figure 30.13 ). A total sensory score is then calculated. Rectal examination is performed to assess anal tone, volun - tary anal contraction and perianal sensa tion. Level of neurological impairment The extent of spinal cord injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification): /uni25CF A: complete spinal cord injury; /uni25CF B: sensation present, motor absent; /uni25CF C: sensation present, motor present but not useful (MRC grade <3/5); /uni25CF D: sensation present, motor useful (MRC grade ≥ 3/5); - /uni25CF E: normal function. Summary box 30.3 Physical examination /uni25CF /uni25CF

Figure 30.12 Spinal log roll. The ASIA neurological scoring system should be used Functional motor power is MRC grade 3/5 or higher

CLASSIFICATION OF SPINAL CORD INJURY ( ISNCSCI ) MOTOR KEY MUSCLES Neurological examination

The American Spinal Injury Association (ASIA) neurological evaluation system ( Figure 30.13 ) is an internationally accepted method of neurological evaluation. Motor function is assessed using the Medical Research Council (MRC) grading system (0–5) in key muscle groups Hans Ludwig Frankel , b. 1932, Clinical Director, The National Spinal Injuries Centre, Stoke Mandeville, UK. ( Figure 30.13 ). A motor score can then be calculated (max - imum 100). Sensory function (light touch and pin prick) is assessed using the dermatomal map ( Figure 30.13 ). A total sensory score is then calculated. Rectal examination is performed to assess anal tone, volun - tary anal contraction and perianal sensa tion. Level of neurological impairment The extent of spinal cord injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification): /uni25CF A: complete spinal cord injury; /uni25CF B: sensation present, motor absent; /uni25CF C: sensation present, motor present but not useful (MRC grade <3/5); /uni25CF D: sensation present, motor useful (MRC grade ≥ 3/5); - /uni25CF E: normal function. Summary box 30.3 Physical examination /uni25CF /uni25CF

Figure 30.12 Spinal log roll. The ASIA neurological scoring system should be used Functional motor power is MRC grade 3/5 or higher

CLASSIFICATION OF SPINAL CORD INJURY ( ISNCSCI ) MOTOR KEY MUSCLES

OUTCOME

OUTCOME

The goal of spinal cord injury rehabilitation is based on a multidisciplinary approach. There is a focus on goal-setting, maximising remaining neurological function and reintegration into employment and society . The level of neurological impair - ment determines the functional outcome ( Table 30.1 ). OUTCOME

The goal of spinal cord injury rehabilitation is based on a multidisciplinary approach. There is a focus on goal-setting, maximising remaining neurological function and reintegration into employment and society . The level of neurological impair - ment determines the functional outcome ( Table 30.1 ). OUTCOME

The goal of spinal cord injury rehabilitation is based on a multidisciplinary approach. There is a focus on goal-setting, maximising remaining neurological function and reintegration into employment and society . The level of neurological impair - ment determines the functional outcome ( Table 30.1 ).

Odontoid fractures

Odontoid fractures

There are three types of odontoid peg fracture ( Figure 30.27 ). Neurological injury is rare. The majority of acute injuries are treated non-operatively in a hard collar or halo jacket for 3 /uni00A0 months. Internal fixation with an anterior compression screw is indicated for displaced fractures ( Figure 30.28 ), and a posterior C1/2 fusion is considered in cases of non-union. In the elderly , treatment in a soft collar should be considered on the basis that a relatively stable pseudarthrosis will occur. Traumatic spondylolisthesis of the axis (hangman’s fracture) This is a traumatic spondylolisthesis of C2 on C3. There are four types with varying degrees of instability ( Figure 30.29 ). Those with significant displacement or associated facet disloca - tion are treated operatively , usually with posterior stabilisation.

(b) Figure 30.26 (a) Atlantoaxial subluxation. (b) C1/2 posterior fusion using C1 lateral mass and C2 pedicle screws. Type I Type II Type III Figure 30.27 Types of odontoid fracture. (b) Figure 30.28 (a) Type II odontoid fracture (arrow); (b) treated with an anterior compression screw.

(b) Figure 30.29 (a) Hangman’s fractures of C2 with minimal forward translation (arrow). (b) C2/3 subluxation with spinal cord contusion.

Odontoid fractures

There are three types of odontoid peg fracture ( Figure 30.27 ). Neurological injury is rare. The majority of acute injuries are treated non-operatively in a hard collar or halo jacket for 3 /uni00A0 months. Internal fixation with an anterior compression screw is indicated for displaced fractures ( Figure 30.28 ), and a posterior C1/2 fusion is considered in cases of non-union. In the elderly , treatment in a soft collar should be considered on the basis that a relatively stable pseudarthrosis will occur. Traumatic spondylolisthesis of the axis (hangman’s fracture) This is a traumatic spondylolisthesis of C2 on C3. There are four types with varying degrees of instability ( Figure 30.29 ). Those with significant displacement or associated facet disloca - tion are treated operatively , usually with posterior stabilisation.

(b) Figure 30.26 (a) Atlantoaxial subluxation. (b) C1/2 posterior fusion using C1 lateral mass and C2 pedicle screws. Type I Type II Type III Figure 30.27 Types of odontoid fracture. (b) Figure 30.28 (a) Type II odontoid fracture (arrow); (b) treated with an anterior compression screw.

(b) Figure 30.29 (a) Hangman’s fractures of C2 with minimal forward translation (arrow). (b) C2/3 subluxation with spinal cord contusion.

Odontoid fractures

There are three types of odontoid peg fracture ( Figure 30.27 ). Neurological injury is rare. The majority of acute injuries are treated non-operatively in a hard collar or halo jacket for 3 /uni00A0 months. Internal fixation with an anterior compression screw is indicated for displaced fractures ( Figure 30.28 ), and a posterior C1/2 fusion is considered in cases of non-union. In the elderly , treatment in a soft collar should be considered on the basis that a relatively stable pseudarthrosis will occur. Traumatic spondylolisthesis of the axis (hangman’s fracture) This is a traumatic spondylolisthesis of C2 on C3. There are four types with varying degrees of instability ( Figure 30.29 ). Those with significant displacement or associated facet disloca - tion are treated operatively , usually with posterior stabilisation.

(b) Figure 30.26 (a) Atlantoaxial subluxation. (b) C1/2 posterior fusion using C1 lateral mass and C2 pedicle screws. Type I Type II Type III Figure 30.27 Types of odontoid fracture. (b) Figure 30.28 (a) Type II odontoid fracture (arrow); (b) treated with an anterior compression screw.

(b) Figure 30.29 (a) Hangman’s fractures of C2 with minimal forward translation (arrow). (b) C2/3 subluxation with spinal cord contusion.

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury

This is the direct insult to the neural elements and occurs at the time of the initial injury .

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury

This is the direct insult to the neural elements and occurs at the time of the initial injury .

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary

PATHOPHYSIOLOGY OF SPINAL CORD INJURY The primary injury

This is the direct insult to the neural elements and occurs at the time of the initial injury .

PATIENT ASSESSMENT Basic points

PATIENT ASSESSMENT Basic points

The Advanced Trauma Life Support (ATLS) principles apply in all cases (see Chapters 26 and 27 ). The spine should initially be immobilised using full spinal precautions, on the assumption that every trauma patient has a spinal injury until proven otherwise ( Figure 30.10 ). The finding of a spinal injury makes it more (not less) likely that there will be a second injury at another level. Spinal boards lead to skin breakdown in insensate patients, and are very uncomfortable for those with normal sensation ( Figur e 30.11 ). They should only be used for transferring patients.

Figure 30.10 Spinal immobilisation. Figure 30.11 Pressure sores may develop rapidly in insensate patients.

Definitive clearance of the spine may not be possible in the initial stages; if this is the case, spinal immobilisation should be maintained until magnetic resonance imaging (MRI) or equivalent can be used to rule out an unstable spinal injury . Summary box 30.2 Patient assessment /uni25CF /uni25CF /uni25CF /uni25CF

Use ATLS principles in all cases of spinal injury In polytrauma cases suspect a spinal injury A second spinal injury at a remote level may be present in 10% of cases Spinal boards cause pressure sores

PATIENT ASSESSMENT Basic points

The Advanced Trauma Life Support (ATLS) principles apply in all cases (see Chapters 26 and 27 ). The spine should initially be immobilised using full spinal precautions, on the assumption that every trauma patient has a spinal injury until proven otherwise ( Figure 30.10 ). The finding of a spinal injury makes it more (not less) likely that there will be a second injury at another level. Spinal boards lead to skin breakdown in insensate patients, and are very uncomfortable for those with normal sensation ( Figur e 30.11 ). They should only be used for transferring patients.

Figure 30.10 Spinal immobilisation. Figure 30.11 Pressure sores may develop rapidly in insensate patients.

Definitive clearance of the spine may not be possible in the initial stages; if this is the case, spinal immobilisation should be maintained until magnetic resonance imaging (MRI) or equivalent can be used to rule out an unstable spinal injury . Summary box 30.2 Patient assessment /uni25CF /uni25CF /uni25CF /uni25CF

Use ATLS principles in all cases of spinal injury In polytrauma cases suspect a spinal injury A second spinal injury at a remote level may be present in 10% of cases Spinal boards cause pressure sores

PATIENT ASSESSMENT Basic points

The Advanced Trauma Life Support (ATLS) principles apply in all cases (see Chapters 26 and 27 ). The spine should initially be immobilised using full spinal precautions, on the assumption that every trauma patient has a spinal injury until proven otherwise ( Figure 30.10 ). The finding of a spinal injury makes it more (not less) likely that there will be a second injury at another level. Spinal boards lead to skin breakdown in insensate patients, and are very uncomfortable for those with normal sensation ( Figur e 30.11 ). They should only be used for transferring patients.

Figure 30.10 Spinal immobilisation. Figure 30.11 Pressure sores may develop rapidly in insensate patients.

Definitive clearance of the spine may not be possible in the initial stages; if this is the case, spinal immobilisation should be maintained until magnetic resonance imaging (MRI) or equivalent can be used to rule out an unstable spinal injury . Summary box 30.2 Patient assessment /uni25CF /uni25CF /uni25CF /uni25CF

Use ATLS principles in all cases of spinal injury In polytrauma cases suspect a spinal injury A second spinal injury at a remote level may be present in 10% of cases Spinal boards cause pressure sores

PERTINENT HISTORY

PERTINENT HISTORY

The mechanism and velocity of injury should be determined at an early stage. A check for the presence of spinal pain should be made. The onset and duration of neurological symptoms should also be recorded. PERTINENT HISTORY

The mechanism and velocity of injury should be determined at an early stage. A check for the presence of spinal pain should be made. The onset and duration of neurological symptoms should also be recorded. PERTINENT HISTORY

The mechanism and velocity of injury should be determined at an early stage. A check for the presence of spinal pain should be made. The onset and duration of neurological symptoms should also be recorded.

PHYSICAL EXAMINATION Initial assessment

PHYSICAL EXAMINATION Initial assessment

The primary survey always takes precedence, followed by a careful systems examination paying particular attention to the abdomen and chest. Spinal cord injury may mask signs of intra-abdominal injury . PHYSICAL EXAMINATION Initial assessment

The primary survey always takes precedence, followed by a careful systems examination paying particular attention to the abdomen and chest. Spinal cord injury may mask signs of intra-abdominal injury . PHYSICAL EXAMINATION Initial assessment

The primary survey always takes precedence, followed by a careful systems examination paying particular attention to the abdomen and chest. Spinal cord injury may mask signs of intra-abdominal injury .

Prognosis of spinal cord injury

Prognosis of spinal cord injury

Despite continuing improvements in patient care, life expec - tancy remains below normal following spinal cord injury . The median life expectancy is 33 years, but varies considerably ( Table 30.2 ). The prognosis for neurological recover y is strongly influ - enced by factors such as the level and completeness of the injury , ventilator dependence and the age at presentation. -

Ventilator Paraplegic Low tetraplegic High dependent at any (C5–C8) tetraplegic level (C1–C4) 45.6 40.6 36.1 16.6 28.0 23.8 20.2 7.1 13.1 10.2 7.9 1.4 46.3 41.7 37.9 23.3 28.6 24.7 21.6 11.1 13.5 10.8 8.8 3.1

Prognosis of spinal cord injury

Despite continuing improvements in patient care, life expec - tancy remains below normal following spinal cord injury . The median life expectancy is 33 years, but varies considerably ( Table 30.2 ). The prognosis for neurological recover y is strongly influ - enced by factors such as the level and completeness of the injury , ventilator dependence and the age at presentation. -

Ventilator Paraplegic Low tetraplegic High dependent at any (C5–C8) tetraplegic level (C1–C4) 45.6 40.6 36.1 16.6 28.0 23.8 20.2 7.1 13.1 10.2 7.9 1.4 46.3 41.7 37.9 23.3 28.6 24.7 21.6 11.1 13.5 10.8 8.8 3.1

Prognosis of spinal cord injury

Despite continuing improvements in patient care, life expec - tancy remains below normal following spinal cord injury . The median life expectancy is 33 years, but varies considerably ( Table 30.2 ). The prognosis for neurological recover y is strongly influ - enced by factors such as the level and completeness of the injury , ventilator dependence and the age at presentation. -

Ventilator Paraplegic Low tetraplegic High dependent at any (C5–C8) tetraplegic level (C1–C4) 45.6 40.6 36.1 16.6 28.0 23.8 20.2 7.1 13.1 10.2 7.9 1.4 46.3 41.7 37.9 23.3 28.6 24.7 21.6 11.1 13.5 10.8 8.8 3.1

RIGHT

RIGHT

Light Touch (LTR) Pin Prick (PPR) C2 C3 C4 C3 Elbow flexors C5 Wrist extensors UER C6 (Upper Extremity Right) Elbow extensors C7 Finger flexors C8 Finger abductors (little finger) T1 T2 Comments (Non-key Muscle? Reason for NT? Pain? C6 Non-SCI condition?): T3 Dorsum T4 T5 T6 T7 T8 S3 T9 T10 T11 2 T12 L S2 3 L1 Hip flexors L2 Knee extensors L3 LER Ankle dorsiflexors L4 (Lower Extremity Right) L Long toe extensors L5 4 S1 Ankle plantar flexors S1 L5 S2 S3 (VAC) Voluntary Anal Contraction S4-5 (Yes/No) RIGHT TOTALS (MAXIMUM) (50) (56) (56) MOTOR SUBSCORES LER +UEL = UEMS TOTAL + LEL = LEMS TOTAL UER MAX MAX (25) (25) (50) (25) (25) R L NEUROLOGICAL 3. NEUROLOGICAL LEVELS 1. SENSORY LEVEL OF INJURY Steps 1- 6 for classification 2. MOTOR (NLI) as on reverse Page 1/2 This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.

Figure 30.13 American Spinal Injury Association neurological evaluation. (Reproduced with permission from American Spinal Injury Association: International standards for neurological classi /f_i cation of spinal cord injury

RIGHT

Light Touch (LTR) Pin Prick (PPR) C2 C3 C4 C3 Elbow flexors C5 Wrist extensors UER C6 (Upper Extremity Right) Elbow extensors C7 Finger flexors C8 Finger abductors (little finger) T1 T2 Comments (Non-key Muscle? Reason for NT? Pain? C6 Non-SCI condition?): T3 Dorsum T4 T5 T6 T7 T8 S3 T9 T10 T11 2 T12 L S2 3 L1 Hip flexors L2 Knee extensors L3 LER Ankle dorsiflexors L4 (Lower Extremity Right) L Long toe extensors L5 4 S1 Ankle plantar flexors S1 L5 S2 S3 (VAC) Voluntary Anal Contraction S4-5 (Yes/No) RIGHT TOTALS (MAXIMUM) (50) (56) (56) MOTOR SUBSCORES LER +UEL = UEMS TOTAL + LEL = LEMS TOTAL UER MAX MAX (25) (25) (50) (25) (25) R L NEUROLOGICAL 3. NEUROLOGICAL LEVELS 1. SENSORY LEVEL OF INJURY Steps 1- 6 for classification 2. MOTOR (NLI) as on reverse Page 1/2 This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.

Figure 30.13 American Spinal Injury Association neurological evaluation. (Reproduced with permission from American Spinal Injury Association: International standards for neurological classi /f_i cation of spinal cord injury

RIGHT

Light Touch (LTR) Pin Prick (PPR) C2 C3 C4 C3 Elbow flexors C5 Wrist extensors UER C6 (Upper Extremity Right) Elbow extensors C7 Finger flexors C8 Finger abductors (little finger) T1 T2 Comments (Non-key Muscle? Reason for NT? Pain? C6 Non-SCI condition?): T3 Dorsum T4 T5 T6 T7 T8 S3 T9 T10 T11 2 T12 L S2 3 L1 Hip flexors L2 Knee extensors L3 LER Ankle dorsiflexors L4 (Lower Extremity Right) L Long toe extensors L5 4 S1 Ankle plantar flexors S1 L5 S2 S3 (VAC) Voluntary Anal Contraction S4-5 (Yes/No) RIGHT TOTALS (MAXIMUM) (50) (56) (56) MOTOR SUBSCORES LER +UEL = UEMS TOTAL + LEL = LEMS TOTAL UER MAX MAX (25) (25) (50) (25) (25) R L NEUROLOGICAL 3. NEUROLOGICAL LEVELS 1. SENSORY LEVEL OF INJURY Steps 1- 6 for classification 2. MOTOR (NLI) as on reverse Page 1/2 This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.

Figure 30.13 American Spinal Injury Association neurological evaluation. (Reproduced with permission from American Spinal Injury Association: International standards for neurological classi /f_i cation of spinal cord injury

Regional variations

Regional variations

Upper cervical spine anatomy is designed to facilitate motion ( Figure 30.3 ), and stability here is dependent on ligamentous restraints ( Figure 30.4 ). V ertebral anatomy from C3 to C7 is similar. The cervicothoracic ( Figure 30.5 ) and thoracolumbar ( Figure 30.6 ) junctions are transitional zones where the spine changes from a mobile section (cervical and lumbar) to a more fixed one (thoracic). These two areas are common sites of injury .

The pathophysiology and types of spinal cord injury • The prognosis of spinal cord injury, factors affecting • functional outcome and common associated complications 1 5 3 2 4 Figure 30.2 Ligamentous spinal restraints. (1) Anterior longitudinal ligament, (2) intervertebral disc and posterior longitudinal ligament, (3) facet joint capsule, (4) interspinous ligament, (5) supraspinous ligament. Atlas Axis (inferior view) (posterosuperior view) Dens Posterior tubercle Superior Posterior Posterior articular articular arch facet facet Inferior Spinous articular process Anterior Anterior facet arch tubercle Figure 30.3 Atlantoaxial bony anatomy.

Ascending band Cruciate Transverse ligament band Posterior longitudinal ligament Figure 30.4 Atlantoaxial ligaments. Figure 30.5 Cervicothoracic facet subluxation (arrow) (easily missed with inadequate radiographs).

Regional variations

Upper cervical spine anatomy is designed to facilitate motion ( Figure 30.3 ), and stability here is dependent on ligamentous restraints ( Figure 30.4 ). V ertebral anatomy from C3 to C7 is similar. The cervicothoracic ( Figure 30.5 ) and thoracolumbar ( Figure 30.6 ) junctions are transitional zones where the spine changes from a mobile section (cervical and lumbar) to a more fixed one (thoracic). These two areas are common sites of injury .

The pathophysiology and types of spinal cord injury • The prognosis of spinal cord injury, factors affecting • functional outcome and common associated complications 1 5 3 2 4 Figure 30.2 Ligamentous spinal restraints. (1) Anterior longitudinal ligament, (2) intervertebral disc and posterior longitudinal ligament, (3) facet joint capsule, (4) interspinous ligament, (5) supraspinous ligament. Atlas Axis (inferior view) (posterosuperior view) Dens Posterior tubercle Superior Posterior Posterior articular articular arch facet facet Inferior Spinous articular process Anterior Anterior facet arch tubercle Figure 30.3 Atlantoaxial bony anatomy.

Ascending band Cruciate Transverse ligament band Posterior longitudinal ligament Figure 30.4 Atlantoaxial ligaments. Figure 30.5 Cervicothoracic facet subluxation (arrow) (easily missed with inadequate radiographs).

Regional variations

Upper cervical spine anatomy is designed to facilitate motion ( Figure 30.3 ), and stability here is dependent on ligamentous restraints ( Figure 30.4 ). V ertebral anatomy from C3 to C7 is similar. The cervicothoracic ( Figure 30.5 ) and thoracolumbar ( Figure 30.6 ) junctions are transitional zones where the spine changes from a mobile section (cervical and lumbar) to a more fixed one (thoracic). These two areas are common sites of injury .

The pathophysiology and types of spinal cord injury • The prognosis of spinal cord injury, factors affecting • functional outcome and common associated complications 1 5 3 2 4 Figure 30.2 Ligamentous spinal restraints. (1) Anterior longitudinal ligament, (2) intervertebral disc and posterior longitudinal ligament, (3) facet joint capsule, (4) interspinous ligament, (5) supraspinous ligament. Atlas Axis (inferior view) (posterosuperior view) Dens Posterior tubercle Superior Posterior Posterior articular articular arch facet facet Inferior Spinous articular process Anterior Anterior facet arch tubercle Figure 30.3 Atlantoaxial bony anatomy.

Ascending band Cruciate Transverse ligament band Posterior longitudinal ligament Figure 30.4 Atlantoaxial ligaments. Figure 30.5 Cervicothoracic facet subluxation (arrow) (easily missed with inadequate radiographs).

SPECIFIC SPINAL INJURIES Upper cervical spine (sku

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2)

Occipital condyle fracture This is a relatively stable injury often associated with head injuries and is best treated in a hard collar for 6–8 weeks. Occipitoatlantal dislocation This injury is usually caused by high-energy trauma and is often fatal. The dislocation may be anterior, posterior or to assess skull translation. Treatment is with a halo brace or occipitocervical fixation. Atlas fracture (Jefferson fracture) Fracture of the C1 ring is associated with axial loading of the cervical spine and may be stable or unstable ( Figure 30.25a,b Associated transverse ligament rupture may occur ( Figure 30.25c ). Most are treated non-operatively in a cervical collar or halo brace. Barry Powers , contemporary , Chief and Clinical Professor of Radiology , Duplin General Hospital, Kenansville, NC, USA, described his ratio in 1979. Sir Geo ff rey Je ff erson , 1886–1961, Professor of Neurosurgery , University of Manchester, UK, became the UK’s first Professor of Neurosurgery in 1939. In 1947 he was elected a Fellow of the Royal Society , a rare distinction for a practising surgeon. Although he became a neurosurgeon, he performed the first successful embolectomy in England in 1925 at Salford Royal Hospital. (a) (b) ).

Figure 30.23 Vertical occipitocervical dislocation. B O A C Figure 30.24 Powers’ ratio. BC/OA ≥ 1 indicates anterior translation; ≤ 0.75 indicates posterior translation. (c) Figure 30.25 Stable (a) versus unstable (b) Jefferson’s fracture of C1. (c) Open mouth view of C1/2 demonstrating C1 lateral mass deviation (arrows). Rupture of the transverse ligament is present when the combined lateral mass deviation exceeds 6.9 mm.

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2)

Occipital condyle fracture This is a relatively stable injury often associated with head injuries and is best treated in a hard collar for 6–8 weeks. Occipitoatlantal dislocation This injury is usually caused by high-energy trauma and is often fatal. The dislocation may be anterior, posterior or to assess skull translation. Treatment is with a halo brace or occipitocervical fixation. Atlas fracture (Jefferson fracture) Fracture of the C1 ring is associated with axial loading of the cervical spine and may be stable or unstable ( Figure 30.25a,b Associated transverse ligament rupture may occur ( Figure 30.25c ). Most are treated non-operatively in a cervical collar or halo brace. Barry Powers , contemporary , Chief and Clinical Professor of Radiology , Duplin General Hospital, Kenansville, NC, USA, described his ratio in 1979. Sir Geo ff rey Je ff erson , 1886–1961, Professor of Neurosurgery , University of Manchester, UK, became the UK’s first Professor of Neurosurgery in 1939. In 1947 he was elected a Fellow of the Royal Society , a rare distinction for a practising surgeon. Although he became a neurosurgeon, he performed the first successful embolectomy in England in 1925 at Salford Royal Hospital. (a) (b) ).

Figure 30.23 Vertical occipitocervical dislocation. B O A C Figure 30.24 Powers’ ratio. BC/OA ≥ 1 indicates anterior translation; ≤ 0.75 indicates posterior translation. (c) Figure 30.25 Stable (a) versus unstable (b) Jefferson’s fracture of C1. (c) Open mouth view of C1/2 demonstrating C1 lateral mass deviation (arrows). Rupture of the transverse ligament is present when the combined lateral mass deviation exceeds 6.9 mm.

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2)

SPECIFIC SPINAL INJURIES Upper cervical spine (skull–C2)

Occipital condyle fracture This is a relatively stable injury often associated with head injuries and is best treated in a hard collar for 6–8 weeks. Occipitoatlantal dislocation This injury is usually caused by high-energy trauma and is often fatal. The dislocation may be anterior, posterior or to assess skull translation. Treatment is with a halo brace or occipitocervical fixation. Atlas fracture (Jefferson fracture) Fracture of the C1 ring is associated with axial loading of the cervical spine and may be stable or unstable ( Figure 30.25a,b Associated transverse ligament rupture may occur ( Figure 30.25c ). Most are treated non-operatively in a cervical collar or halo brace. Barry Powers , contemporary , Chief and Clinical Professor of Radiology , Duplin General Hospital, Kenansville, NC, USA, described his ratio in 1979. Sir Geo ff rey Je ff erson , 1886–1961, Professor of Neurosurgery , University of Manchester, UK, became the UK’s first Professor of Neurosurgery in 1939. In 1947 he was elected a Fellow of the Royal Society , a rare distinction for a practising surgeon. Although he became a neurosurgeon, he performed the first successful embolectomy in England in 1925 at Salford Royal Hospital. (a) (b) ).

Figure 30.23 Vertical occipitocervical dislocation. B O A C Figure 30.24 Powers’ ratio. BC/OA ≥ 1 indicates anterior translation; ≤ 0.75 indicates posterior translation. (c) Figure 30.25 Stable (a) versus unstable (b) Jefferson’s fracture of C1. (c) Open mouth view of C1/2 demonstrating C1 lateral mass deviation (arrows). Rupture of the transverse ligament is present when the combined lateral mass deviation exceeds 6.9 mm.

Spinal examination

Spinal examination

The overlying skin should be inspected (e.g. for possible penetrating wounds) and the entire spine must be palpated. A formal spinal log roll must be performed to achieve this ( Figure 30.12 ). Significant swelling, tenderness, palpable steps or gaps suggest a spinal injury . A rectal examination should be undertaken to assess anal tone and perianal sensation (see Neurological examination ). Seatbelt marks on the abdomen and chest must be noted, as these suggest a high-energy acci dent. Spinal examination

The overlying skin should be inspected (e.g. for possible penetrating wounds) and the entire spine must be palpated. A formal spinal log roll must be performed to achieve this ( Figure 30.12 ). Significant swelling, tenderness, palpable steps or gaps suggest a spinal injury . A rectal examination should be undertaken to assess anal tone and perianal sensation (see Neurological examination ). Seatbelt marks on the abdomen and chest must be noted, as these suggest a high-energy acci dent. Spinal examination

The overlying skin should be inspected (e.g. for possible penetrating wounds) and the entire spine must be palpated. A formal spinal log roll must be performed to achieve this ( Figure 30.12 ). Significant swelling, tenderness, palpable steps or gaps suggest a spinal injury . A rectal examination should be undertaken to assess anal tone and perianal sensation (see Neurological examination ). Seatbelt marks on the abdomen and chest must be noted, as these suggest a high-energy acci dent.

Spinal neuroanatomy

Spinal neuroanatomy

• The spinal cord extends from the foramen magnum to the L1/ L2 level, where it ends as the conus medullaris in adults (lower in children) ( Figure 30.8 ). Below this level lies the cauda equina. ). If Figure 30.9 illustrates a cross-section of the spinal cord.

Middle Posterior

The lateral spinothalamic tracts transmit the sensations of pain and temperature, the lateral corticospinal tracts are responsible for motor function and the posterior columns transmit position, vibration and deep pressure sensation. The spinothalamic tracts cross to the opposite side of the spinal cord within three levels of entering the cord. In contrast, the corticospinal tracts and the posterior columns decussate proximally at the craniocervical level. The tracts represented centrally , with distal body function arranged peripherally .

Cord Conus medullari s Cauda equina Figure 30.8 The spinal cord ends at L1/L2 at the conus medullaris, which gives rise to the cauda equina. Fasciculus gracilis Dorsal Dorsal Fasciculus sulcus column cuneatus Lateral S C column T L Lateral corticospinal L T tract C Lateral S L spinothalamic T tract C Ventral Ventral Anterior column /f_i ssure spinothalamic tract Figure 30.9 A cross-section of the spinal cord. C, cervical; L, lumbar; S, sacral; T, thoracic.

Spinal neuroanatomy

• The spinal cord extends from the foramen magnum to the L1/ L2 level, where it ends as the conus medullaris in adults (lower in children) ( Figure 30.8 ). Below this level lies the cauda equina. ). If Figure 30.9 illustrates a cross-section of the spinal cord.

Middle Posterior

The lateral spinothalamic tracts transmit the sensations of pain and temperature, the lateral corticospinal tracts are responsible for motor function and the posterior columns transmit position, vibration and deep pressure sensation. The spinothalamic tracts cross to the opposite side of the spinal cord within three levels of entering the cord. In contrast, the corticospinal tracts and the posterior columns decussate proximally at the craniocervical level. The tracts represented centrally , with distal body function arranged peripherally .

Cord Conus medullari s Cauda equina Figure 30.8 The spinal cord ends at L1/L2 at the conus medullaris, which gives rise to the cauda equina. Fasciculus gracilis Dorsal Dorsal Fasciculus sulcus column cuneatus Lateral S C column T L Lateral corticospinal L T tract C Lateral S L spinothalamic T tract C Ventral Ventral Anterior column /f_i ssure spinothalamic tract Figure 30.9 A cross-section of the spinal cord. C, cervical; L, lumbar; S, sacral; T, thoracic.

Spinal neuroanatomy

• The spinal cord extends from the foramen magnum to the L1/ L2 level, where it ends as the conus medullaris in adults (lower in children) ( Figure 30.8 ). Below this level lies the cauda equina. ). If Figure 30.9 illustrates a cross-section of the spinal cord.

Middle Posterior

The lateral spinothalamic tracts transmit the sensations of pain and temperature, the lateral corticospinal tracts are responsible for motor function and the posterior columns transmit position, vibration and deep pressure sensation. The spinothalamic tracts cross to the opposite side of the spinal cord within three levels of entering the cord. In contrast, the corticospinal tracts and the posterior columns decussate proximally at the craniocervical level. The tracts represented centrally , with distal body function arranged peripherally .

Cord Conus medullari s Cauda equina Figure 30.8 The spinal cord ends at L1/L2 at the conus medullaris, which gives rise to the cauda equina. Fasciculus gracilis Dorsal Dorsal Fasciculus sulcus column cuneatus Lateral S C column T L Lateral corticospinal L T tract C Lateral S L spinothalamic T tract C Ventral Ventral Anterior column /f_i ssure spinothalamic tract Figure 30.9 A cross-section of the spinal cord. C, cervical; L, lumbar; S, sacral; T, thoracic.

Spinal stability

Spinal stability

Spinal stability is the ability of the spine to withstand phys iological loads with acceptable pain, avoiding progressive deformity or neurological deficit. The spine can be divided into three columns: anterior, middle and posterior ( Figure 30.7 two or more columns of the spine are injured, it is considered Friedrich Paul Magerl , 1931–2020, Austrian surgeon and pioneer of spinal surgery . AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. unstable. The AO classifications (Magerl and AO Spine Subaxial Classification System) are based on the mechanism of injury and are used to assess spinal stability . Summary box 30.1 Spinal column anatomy /uni25CF /uni25CF

Anterior Figure 30.7 The three-column model of spinal stability. Figure 30.6 Coronal T2-weighted magnetic resonance image demon

strating a fracture dislocation at the thoracolumbar junction. Upper cervical spine stability is dependent on ligamentous restraints The cervicothoracic and thoracolumbar junctions are common sites of injury

Spinal stability

Spinal stability is the ability of the spine to withstand phys iological loads with acceptable pain, avoiding progressive deformity or neurological deficit. The spine can be divided into three columns: anterior, middle and posterior ( Figure 30.7 two or more columns of the spine are injured, it is considered Friedrich Paul Magerl , 1931–2020, Austrian surgeon and pioneer of spinal surgery . AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. unstable. The AO classifications (Magerl and AO Spine Subaxial Classification System) are based on the mechanism of injury and are used to assess spinal stability . Summary box 30.1 Spinal column anatomy /uni25CF /uni25CF

Anterior Figure 30.7 The three-column model of spinal stability. Figure 30.6 Coronal T2-weighted magnetic resonance image demon

strating a fracture dislocation at the thoracolumbar junction. Upper cervical spine stability is dependent on ligamentous restraints The cervicothoracic and thoracolumbar junctions are common sites of injury

Spinal stability

Spinal stability is the ability of the spine to withstand phys iological loads with acceptable pain, avoiding progressive deformity or neurological deficit. The spine can be divided into three columns: anterior, middle and posterior ( Figure 30.7 two or more columns of the spine are injured, it is considered Friedrich Paul Magerl , 1931–2020, Austrian surgeon and pioneer of spinal surgery . AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. unstable. The AO classifications (Magerl and AO Spine Subaxial Classification System) are based on the mechanism of injury and are used to assess spinal stability . Summary box 30.1 Spinal column anatomy /uni25CF /uni25CF

Anterior Figure 30.7 The three-column model of spinal stability. Figure 30.6 Coronal T2-weighted magnetic resonance image demon

strating a fracture dislocation at the thoracolumbar junction. Upper cervical spine stability is dependent on ligamentous restraints The cervicothoracic and thoracolumbar junctions are common sites of injury

Subaxial cervical spine (C3–C7)

Subaxial cervical spine (C3–C7)

The pattern of lower cervical spine injury depends on the mechanism of trauma. These include compression fractures (hyperflexion), burst fractures (axial compression), facet subluxation/dislocation injuries (distraction–flexion), teardrop fractures (hyperextension) and fracture of posterior elements. The more severe injuries may have an associated spinal cord injury ( Figure 30.30a ). Operative intervention may be required to decompress the spinal cord and to stabilise the spine with internal fixation ( Figure 30.30b ). Facet subluxation/dislocation ranges in severity from minor instability to complete dislocation with spinal cord injury ( Figure 30.31 ).

(b) Figure 30.30 (a) Cervical burst fracture with spinal cord contusion; (b) /uni00A0 treated with anterior decompression and reconstruction.

Subaxial cervical spine (C3–C7)

The pattern of lower cervical spine injury depends on the mechanism of trauma. These include compression fractures (hyperflexion), burst fractures (axial compression), facet subluxation/dislocation injuries (distraction–flexion), teardrop fractures (hyperextension) and fracture of posterior elements. The more severe injuries may have an associated spinal cord injury ( Figure 30.30a ). Operative intervention may be required to decompress the spinal cord and to stabilise the spine with internal fixation ( Figure 30.30b ). Facet subluxation/dislocation ranges in severity from minor instability to complete dislocation with spinal cord injury ( Figure 30.31 ).

(b) Figure 30.30 (a) Cervical burst fracture with spinal cord contusion; (b) /uni00A0 treated with anterior decompression and reconstruction.

Subaxial cervical spine (C3–C7)

The pattern of lower cervical spine injury depends on the mechanism of trauma. These include compression fractures (hyperflexion), burst fractures (axial compression), facet subluxation/dislocation injuries (distraction–flexion), teardrop fractures (hyperextension) and fracture of posterior elements. The more severe injuries may have an associated spinal cord injury ( Figure 30.30a ). Operative intervention may be required to decompress the spinal cord and to stabilise the spine with internal fixation ( Figure 30.30b ). Facet subluxation/dislocation ranges in severity from minor instability to complete dislocation with spinal cord injury ( Figure 30.31 ).

(b) Figure 30.30 (a) Cervical burst fracture with spinal cord contusion; (b) /uni00A0 treated with anterior decompression and reconstruction.

The secondary injury

The secondary injury

Haemorrhage, oedema and ischaemia result in a biochemical cascade that causes the secondary injury . This may be accen tuated by hypotension, hypoxia, spinal instability and/or persistent compression of the neural elements. Management of spinal cord injury must focus on minimising secondary injury . Donald Munro , 1889–1973, established the first spinal cord unit in the USA at the Boston City Hospital, Boston, MD, USA. Sir Ludwig Guttmann , 1899–1980, considered by many to be the father of spinal cord medicine. He was a leading neurosurgeon in Germany , working at the Jewish Hospital in Breslau. He fled to England in 1939. Frederic Eugene Basil Foley , 1891–1966, urologist, Ancker Hospital, St Paul, MN, USA. Pathophysiology of spinal cord injury /uni25CF /uni25CF /uni25CF

The spinal cord contains various tracts that are topographically arranged Spinal cord injury involves both primary and secondary phases Therapeutic strategies are directed at reducing the secondary injury

The secondary injury

Haemorrhage, oedema and ischaemia result in a biochemical cascade that causes the secondary injury . This may be accen tuated by hypotension, hypoxia, spinal instability and/or persistent compression of the neural elements. Management of spinal cord injury must focus on minimising secondary injury . Donald Munro , 1889–1973, established the first spinal cord unit in the USA at the Boston City Hospital, Boston, MD, USA. Sir Ludwig Guttmann , 1899–1980, considered by many to be the father of spinal cord medicine. He was a leading neurosurgeon in Germany , working at the Jewish Hospital in Breslau. He fled to England in 1939. Frederic Eugene Basil Foley , 1891–1966, urologist, Ancker Hospital, St Paul, MN, USA. Pathophysiology of spinal cord injury /uni25CF /uni25CF /uni25CF

The spinal cord contains various tracts that are topographically arranged Spinal cord injury involves both primary and secondary phases Therapeutic strategies are directed at reducing the secondary injury

The secondary injury

Haemorrhage, oedema and ischaemia result in a biochemical cascade that causes the secondary injury . This may be accen tuated by hypotension, hypoxia, spinal instability and/or persistent compression of the neural elements. Management of spinal cord injury must focus on minimising secondary injury . Donald Munro , 1889–1973, established the first spinal cord unit in the USA at the Boston City Hospital, Boston, MD, USA. Sir Ludwig Guttmann , 1899–1980, considered by many to be the father of spinal cord medicine. He was a leading neurosurgeon in Germany , working at the Jewish Hospital in Breslau. He fled to England in 1939. Frederic Eugene Basil Foley , 1891–1966, urologist, Ancker Hospital, St Paul, MN, USA. Pathophysiology of spinal cord injury /uni25CF /uni25CF /uni25CF

The spinal cord contains various tracts that are topographically arranged Spinal cord injury involves both primary and secondary phases Therapeutic strategies are directed at reducing the secondary injury

Thoracic and thoracolumbar fractures

Thoracic and thoracolumbar fractures

The system developed by the AO (Arbeitsgemeinschaft für Osteosynthesefragen) can be used to classify these fractures. There are three main injury types, A, B and C, with increasing instability and risk of neurological injury . Type A fractures are vertebral body compression fractures. Type B injuries involve distraction of the anterior or posterior elements and type C injuries are rotational and often coexist with type A or type B injuries. The majority of type B and type C injuries require surgical stabilisation. Thoracic spine (T1–T10) Osteoporotic wedge compression fractures in older adults are the commonest injury in this group. Most of these fractures heal, but symptomatic fractures can be treated with percuta neous bone cement augmentation, known as vertebroplasty or kyphoplasty ( Figure 30.32 ). (b) In trauma cases, unstable fractures are associated with sig - nificant energy transfer to the patient and may be associated with major internal injuries, such as pulmonary contusion and spinal cord injury . The combination of thoracic spine disrup - tion and a sternal fracture ( Figure 30.33 ) also carries a sig - nificant risk of aortic rupture. Multiple posterior rib fractures and rib dislocations above and below a thoracic spinal injury signify a major rotational injury to the chest and can be associ - ated with vascular injury and significant pulmonary contusion ( Figure 30.34 ). Multimodality diagnostic imaging is r ecom - - mended. Surgery is appropriate for most thoracic injuries if unstable.

80 67 Figure 30.32 (a) Lateral radiograph showing multiple osteoporotic compression fractures. (b) Reduction in thoracic kyphotic deformity following four-level kyphoplasty.

George Quentin Chance , Director of Diagnostic Radiology , The Derby Group of Hospitals, Derby , UK. The thoracolumbar junction is especially prone to injury . This can vary from a minor wedge fracture to spinal dislocation ( Figure 30.35 ). Burst fractures are comminuted fractures of the vertebral body . They are characterised by widening of the distance between the pedicles and can be associated with retropulsion of bone fragments into the spinal canal ( Figure 30.36 ). Anterior surgery for this type of fracture is now very rarely used and the current treatment principles involve posterior fixation ( Figure 30.37 ). Chance fractures

Figure 30.33 Sagittal computed tomography reconstruction showing an upper thoracic spine fracture dislocation (long arrow) and an asso ciated sternal fracture (short arrow). Figure 30.34 Rotational (type C) injury at the thoracolumbar junction. Note rib fractures (long arrows) and dislocation (short arrow), and the presence of a chest tube. (a) (b)

Figure 30.35 Total spinal sagittal computed tomography reconstruc

tion demonstrating a thoracolumbar fracture dislocation (long arrow) and fracture of L5 (short arrow). Figure 30.36 Lumbar burst fracture with an increase in the interpedic

ular distance (a) (arrow) and spinal canal compromise (b) .

are flexion–distraction injuries of the thoracolumbar junction and are classically associated with the use of lap belts ( Figure 30.38 ). Duodenal, pancreatic and/or aortic ruptures are also associated with these injuries. Lumbar spinal fractures (L3–S1) Most fractures of the lower lumbar spine can be treated non-surgically because the incidence of neurological injury is lower. The neural canal is more capacious at this level (the spinal cord terminates at L1/L2). Owing to the lumbar lordosis, patients with these injuries are less likely to develop a kyphotic deformity than those with injuries at the thoraco - lumbar junction. Summary box 30.7 Thoracic and thoracolumbar fractures /uni25CF

Figure 30.37 Lumbar burst fracture at L2 (a) , and posterior instrumentation with indirect reduction Figure 30.38 A bony Chance fracture at the thoracolumbar junction (arrow) secondary to a lap-belt injury. (b) . Unstable thoracic spine fractures and thoracolumbar /f_l exion– distraction injuries are commonly associated with vascular and/or visceral injuries

Thoracic and thoracolumbar fractures

The system developed by the AO (Arbeitsgemeinschaft für Osteosynthesefragen) can be used to classify these fractures. There are three main injury types, A, B and C, with increasing instability and risk of neurological injury . Type A fractures are vertebral body compression fractures. Type B injuries involve distraction of the anterior or posterior elements and type C injuries are rotational and often coexist with type A or type B injuries. The majority of type B and type C injuries require surgical stabilisation. Thoracic spine (T1–T10) Osteoporotic wedge compression fractures in older adults are the commonest injury in this group. Most of these fractures heal, but symptomatic fractures can be treated with percuta neous bone cement augmentation, known as vertebroplasty or kyphoplasty ( Figure 30.32 ). (b) In trauma cases, unstable fractures are associated with sig - nificant energy transfer to the patient and may be associated with major internal injuries, such as pulmonary contusion and spinal cord injury . The combination of thoracic spine disrup - tion and a sternal fracture ( Figure 30.33 ) also carries a sig - nificant risk of aortic rupture. Multiple posterior rib fractures and rib dislocations above and below a thoracic spinal injury signify a major rotational injury to the chest and can be associ - ated with vascular injury and significant pulmonary contusion ( Figure 30.34 ). Multimodality diagnostic imaging is r ecom - - mended. Surgery is appropriate for most thoracic injuries if unstable.

80 67 Figure 30.32 (a) Lateral radiograph showing multiple osteoporotic compression fractures. (b) Reduction in thoracic kyphotic deformity following four-level kyphoplasty.

George Quentin Chance , Director of Diagnostic Radiology , The Derby Group of Hospitals, Derby , UK. The thoracolumbar junction is especially prone to injury . This can vary from a minor wedge fracture to spinal dislocation ( Figure 30.35 ). Burst fractures are comminuted fractures of the vertebral body . They are characterised by widening of the distance between the pedicles and can be associated with retropulsion of bone fragments into the spinal canal ( Figure 30.36 ). Anterior surgery for this type of fracture is now very rarely used and the current treatment principles involve posterior fixation ( Figure 30.37 ). Chance fractures

Figure 30.33 Sagittal computed tomography reconstruction showing an upper thoracic spine fracture dislocation (long arrow) and an asso ciated sternal fracture (short arrow). Figure 30.34 Rotational (type C) injury at the thoracolumbar junction. Note rib fractures (long arrows) and dislocation (short arrow), and the presence of a chest tube. (a) (b)

Figure 30.35 Total spinal sagittal computed tomography reconstruc

tion demonstrating a thoracolumbar fracture dislocation (long arrow) and fracture of L5 (short arrow). Figure 30.36 Lumbar burst fracture with an increase in the interpedic

ular distance (a) (arrow) and spinal canal compromise (b) .

are flexion–distraction injuries of the thoracolumbar junction and are classically associated with the use of lap belts ( Figure 30.38 ). Duodenal, pancreatic and/or aortic ruptures are also associated with these injuries. Lumbar spinal fractures (L3–S1) Most fractures of the lower lumbar spine can be treated non-surgically because the incidence of neurological injury is lower. The neural canal is more capacious at this level (the spinal cord terminates at L1/L2). Owing to the lumbar lordosis, patients with these injuries are less likely to develop a kyphotic deformity than those with injuries at the thoraco - lumbar junction. Summary box 30.7 Thoracic and thoracolumbar fractures /uni25CF

Figure 30.37 Lumbar burst fracture at L2 (a) , and posterior instrumentation with indirect reduction Figure 30.38 A bony Chance fracture at the thoracolumbar junction (arrow) secondary to a lap-belt injury. (b) . Unstable thoracic spine fractures and thoracolumbar /f_l exion– distraction injuries are commonly associated with vascular and/or visceral injuries

Thoracic and thoracolumbar fractures

The system developed by the AO (Arbeitsgemeinschaft für Osteosynthesefragen) can be used to classify these fractures. There are three main injury types, A, B and C, with increasing instability and risk of neurological injury . Type A fractures are vertebral body compression fractures. Type B injuries involve distraction of the anterior or posterior elements and type C injuries are rotational and often coexist with type A or type B injuries. The majority of type B and type C injuries require surgical stabilisation. Thoracic spine (T1–T10) Osteoporotic wedge compression fractures in older adults are the commonest injury in this group. Most of these fractures heal, but symptomatic fractures can be treated with percuta neous bone cement augmentation, known as vertebroplasty or kyphoplasty ( Figure 30.32 ). (b) In trauma cases, unstable fractures are associated with sig - nificant energy transfer to the patient and may be associated with major internal injuries, such as pulmonary contusion and spinal cord injury . The combination of thoracic spine disrup - tion and a sternal fracture ( Figure 30.33 ) also carries a sig - nificant risk of aortic rupture. Multiple posterior rib fractures and rib dislocations above and below a thoracic spinal injury signify a major rotational injury to the chest and can be associ - ated with vascular injury and significant pulmonary contusion ( Figure 30.34 ). Multimodality diagnostic imaging is r ecom - - mended. Surgery is appropriate for most thoracic injuries if unstable.

80 67 Figure 30.32 (a) Lateral radiograph showing multiple osteoporotic compression fractures. (b) Reduction in thoracic kyphotic deformity following four-level kyphoplasty.

George Quentin Chance , Director of Diagnostic Radiology , The Derby Group of Hospitals, Derby , UK. The thoracolumbar junction is especially prone to injury . This can vary from a minor wedge fracture to spinal dislocation ( Figure 30.35 ). Burst fractures are comminuted fractures of the vertebral body . They are characterised by widening of the distance between the pedicles and can be associated with retropulsion of bone fragments into the spinal canal ( Figure 30.36 ). Anterior surgery for this type of fracture is now very rarely used and the current treatment principles involve posterior fixation ( Figure 30.37 ). Chance fractures

Figure 30.33 Sagittal computed tomography reconstruction showing an upper thoracic spine fracture dislocation (long arrow) and an asso ciated sternal fracture (short arrow). Figure 30.34 Rotational (type C) injury at the thoracolumbar junction. Note rib fractures (long arrows) and dislocation (short arrow), and the presence of a chest tube. (a) (b)

Figure 30.35 Total spinal sagittal computed tomography reconstruc

tion demonstrating a thoracolumbar fracture dislocation (long arrow) and fracture of L5 (short arrow). Figure 30.36 Lumbar burst fracture with an increase in the interpedic

ular distance (a) (arrow) and spinal canal compromise (b) .

are flexion–distraction injuries of the thoracolumbar junction and are classically associated with the use of lap belts ( Figure 30.38 ). Duodenal, pancreatic and/or aortic ruptures are also associated with these injuries. Lumbar spinal fractures (L3–S1) Most fractures of the lower lumbar spine can be treated non-surgically because the incidence of neurological injury is lower. The neural canal is more capacious at this level (the spinal cord terminates at L1/L2). Owing to the lumbar lordosis, patients with these injuries are less likely to develop a kyphotic deformity than those with injuries at the thoraco - lumbar junction. Summary box 30.7 Thoracic and thoracolumbar fractures /uni25CF

Figure 30.37 Lumbar burst fracture at L2 (a) , and posterior instrumentation with indirect reduction Figure 30.38 A bony Chance fracture at the thoracolumbar junction (arrow) secondary to a lap-belt injury. (b) . Unstable thoracic spine fractures and thoracolumbar /f_l exion– distraction injuries are commonly associated with vascular and/or visceral injuries

cord injury

cord injury

Pressure ulcers Many are preventable. Patients should be turned regularly on an appropriate mattress to minimise the risk of skin breakdown. Pain and spasticity Neurogenic pain is common. Once reflex activity returns following cord injury , spasticity may occur and can be prob lematic. Intrathecal infusion of baclofen may be required in resistant cases. Autonomic dysreflexia This is a paroxysmal syndrome of hypertension, hyperhidrosis (above the level of injury), bradycardia, flushing and headache in response to noxious visceral and other stimuli. It is most commonly triggered by bladder distension or rectal loading from faecal impaction. Neurological deterioration Post-traumatic syringomyelia may occur in around 28% of patients with spinal cord injury up to 30 years following injury . Approximately 30% of cases are symptomatic. Clinically , patients present with segmental pain at or above the level of injury , sensory loss, progressive asymmetrical weakness or increased spasticity . This warrants early MRI assessment. Expanding cavities require neurosurgical intervention. Thromboembolic events Deep vein thrombosis occurs in 30% of patients with spinal cord injury . Fatal pulmonary embolus is reported in 1–2% of cases. Thromboprophylaxis with compression stockings and low-molecular-weight heparin is indicated, provided there are no contraindications. contractures Disuse osteoporosis is an inevitable consequence of spinal cord injury and fragility fractures may occur. Heterotopic ossification may a ff ect the hips, knees, shoulders and elbows. It occurs in 25% of patients with spinal cord injury . Surgery is appropriate in selected cases. Soft-tissue contractures around joints may occur as a result of spasticity but can be avoided by appropriate physical therapy , positioning and splinting. - cord injury

Pressure ulcers Many are preventable. Patients should be turned regularly on an appropriate mattress to minimise the risk of skin breakdown. Pain and spasticity Neurogenic pain is common. Once reflex activity returns following cord injury , spasticity may occur and can be prob lematic. Intrathecal infusion of baclofen may be required in resistant cases. Autonomic dysreflexia This is a paroxysmal syndrome of hypertension, hyperhidrosis (above the level of injury), bradycardia, flushing and headache in response to noxious visceral and other stimuli. It is most commonly triggered by bladder distension or rectal loading from faecal impaction. Neurological deterioration Post-traumatic syringomyelia may occur in around 28% of patients with spinal cord injury up to 30 years following injury . Approximately 30% of cases are symptomatic. Clinically , patients present with segmental pain at or above the level of injury , sensory loss, progressive asymmetrical weakness or increased spasticity . This warrants early MRI assessment. Expanding cavities require neurosurgical intervention. Thromboembolic events Deep vein thrombosis occurs in 30% of patients with spinal cord injury . Fatal pulmonary embolus is reported in 1–2% of cases. Thromboprophylaxis with compression stockings and low-molecular-weight heparin is indicated, provided there are no contraindications. contractures Disuse osteoporosis is an inevitable consequence of spinal cord injury and fragility fractures may occur. Heterotopic ossification may a ff ect the hips, knees, shoulders and elbows. It occurs in 25% of patients with spinal cord injury . Surgery is appropriate in selected cases. Soft-tissue contractures around joints may occur as a result of spasticity but can be avoided by appropriate physical therapy , positioning and splinting. - cord injury

Pressure ulcers Many are preventable. Patients should be turned regularly on an appropriate mattress to minimise the risk of skin breakdown. Pain and spasticity Neurogenic pain is common. Once reflex activity returns following cord injury , spasticity may occur and can be prob lematic. Intrathecal infusion of baclofen may be required in resistant cases. Autonomic dysreflexia This is a paroxysmal syndrome of hypertension, hyperhidrosis (above the level of injury), bradycardia, flushing and headache in response to noxious visceral and other stimuli. It is most commonly triggered by bladder distension or rectal loading from faecal impaction. Neurological deterioration Post-traumatic syringomyelia may occur in around 28% of patients with spinal cord injury up to 30 years following injury . Approximately 30% of cases are symptomatic. Clinically , patients present with segmental pain at or above the level of injury , sensory loss, progressive asymmetrical weakness or increased spasticity . This warrants early MRI assessment. Expanding cavities require neurosurgical intervention. Thromboembolic events Deep vein thrombosis occurs in 30% of patients with spinal cord injury . Fatal pulmonary embolus is reported in 1–2% of cases. Thromboprophylaxis with compression stockings and low-molecular-weight heparin is indicated, provided there are no contraindications. contractures Disuse osteoporosis is an inevitable consequence of spinal cord injury and fragility fractures may occur. Heterotopic ossification may a ff ect the hips, knees, shoulders and elbows. It occurs in 25% of patients with spinal cord injury . Surgery is appropriate in selected cases. Soft-tissue contractures around joints may occur as a result of spasticity but can be avoided by appropriate physical therapy , positioning and splinting. -