SpINE: INJURIES AND DISORDERS😊

SKULL XRAY PATTERN APPROACH

SpINE: INJURIES AND DISORDERS

Anatomy of Vertebrae

• Typical vertebral anatomy:
• Parts: 
• Body,
• Pedicle,
• Lamina,
• Vertebral Arch,
• Intervertebral Disc,
• Transverse Process,
• Spinous Process,
• Superior Articular Process,
• Inferior Articular Process.

• Key Relationship: 
• Part of vertebrae between superior and inferior articular facet:
• Pars interarticularis.

Common Spinal Injuries

• Most Common (m/c) Site:
• Vertebral fracture: Lower thoracic/T12.
• 12 manikk T kittanam → Nattellu adich pottikkum
• Vertebral dislocation: Cervical spine (Due to horizontally arranged articular facets).
• Spinal cord injury: Cervical spine (Thickest part of spinal cord).

Bulbocavernous Reflex in Spinal Shock

• First reflex to disappear after spinal shock.

• First reflex to return after spinal shock.

• Spinal level: S2, S3, S4.

Elicitation

• Squeeze glans penis or clitoris.

• Tap penile or clitoral shaft.

Response

• Contraction of bulbocavernosus muscle.

• Downward movement of anus and base of penis/clitoris.

Reason

• Reflex arc is short, involving only a few spinal segments.

SCIWORA (Spinal Cord Injury Without Radiological Abnormality)

• Common in: Children.

• Cause: Trauma.

• Imaging findings:
• CT & plain X-ray → Often normal.
• MRI → Detects spinal cord changes.

• Importance:
• Negative CT/X-ray does not rule out spinal cord injury.

• Treatment:
• Early (<6 hrs) high-dose methylprednisolone → Improves outcome.

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Aka Forrestiere’s disease

• New bone formation along Anterior longitudinal ligament

• X-ray finding:
• Calcification & ossification of ligaments and entheses.

• Common site:
• Axial skeleton, especially thoracic spine.

• Other involvement: Can affect other spinal segments.

• Fusion of vertebrae anteriorly:
• Flowing wax ossification.

Spinal Fractures

JEFFERSON'S FRACTURE:

• Definition: 4 part Fracture of C1 (Atlas).

• Cause: Axial loading/compression.

• Consequence: Fragments burst away.

• Clinical Feature: No neurological damage → Stable spinal cord

HANGMAN'S FRACTURE:

• Pars interarticularis fracture.

• Definition:
• Fracture dislocation of C2 over C3.
• Axial loading with hyperextension

• D/t distraction and extension force

• Spondylolysis:
• Defined as Pars interarticularis fracture.

• Spondylolisthesis
• Slipping of C2 over C3

CLAY SHOVELER'S FRACTURE:

• Mechanism: 
• Shoveling
• Strong contraction of upper limb muscles
• Avulsion of C7 spinous process (C7 > T1).

CHANCE FRACTURE:

• Long trip → chance (chance fracture) of → Guy coming with knife (Jackknife) → sudden break

• All coloumns are involved

• Also known as: 
• AKA Jackknife Fracture / Seatbelt Fracture.

• It is unstable #

• Mechanism of injury: 
1. Car impact with seatbelt on without shoulder harness
2. Flexion at
• lower thoracic,
• upper lumbar spine
3. + distraction forces
4. ⇒ Fracture of spine (Posterior to anterior).

Compression vs. Burst Fractures

Feature	Compression Fracture	Burst Fracture
Causative Factor	Osteoporosis	Significant trauma → with retopulsion?
Mechanism	Flexion → Compression	Axial loading
Characteristic Features	Wedging of vertebra (Anterior column shortened, posterior column maintained)	Convex anterior & posterior walls
Cord damage	Minimal	ㅤ

Prolapsed Intervertebral Disc (PIVD)

Most common (m/c): 

• L4-L5 > L5-S1.

• Affect the traversing nerve, not nerve at same level
• Example
• L4-L5 affect L5

Effect: 

• Leads to compression of spinal nerves

 

Types of PIVD:

• Paracentral (m/c):
• Impinges traversing nerve roots.

• Far-lateral:
• Impinges exiting nerve roots.

Presentation:

• History of lifting heavy objects.

• Sciatica (PIVD m/c):
• Pain radiating from back to limbs.

Management:

SLRT (Straight Leg Raising Test): 

• Causes stretching of compressed nerve,

• producing pain.

Progression of Disc Prolapse: 

• Degeneration → Prolapse → Extrusion → Sequestration.

Neurological Examination for Nerve Roots

C1, C2

• Function: Neck flexion, neck extension

• Dermatome: None

C3

• Function: Lateral neck flexion, diaphragm

• Dermatome: Clavicles

C4

• Function: Shrugging shoulders (via spinal accessory nerve)

• Dermatome: Clavicles

C5

• Function:
• Shoulder movement
• Arm raising
• Elbow flexion

• Dermatome: Deltoid region

C6 → siX

• Function:
• Arm external rotation
• Wrist extension
• Elbow extension
• Wrist pronation

• Dermatome: Lateral arm/forearm

C7

• Function:
• Wrist flexion
• Small hand muscles
• Elbow extension

• Dermatome: Middle finger

C8

• Function:
• Finger flexion
• Thumb abduction & extension
• Wrist ulnar deviation

• Dermatome: Little finger

T1

• Function: Finger abduction, finger adduction

• Dermatome: None

Thigh (3 Nerve Roots)

• L1: Groin and pelvic girdle

• L2: Anterior thigh

• L3: Inner (medial) thigh and distal anterior thigh

---

Shin (2 Nerve Roots)

• L4: Inner (medial) shin

• L5: Outer (lateral) shin and dorsum of the foot

---

Foot (1 Nerve Root)

• S1: Lateral foot

 

Mnemonic:

• 3 in the thigh: L1, L2, L3

• 2 in the shin: L4, L5

• 1 in the foot: S1

Clinical Examples

Example 1:

• Case: Man with low back pain shooting down right leg after lifting heavy objects.
• Ankle and knee reflexes: Intact
• Sensory loss: Dorsum of right foot

• Likely nerve root: L5

Example 2:

• Case: Diabetic patient with normal reflexes and motor function.
• Sensory deficit: Fine touch on medial aspect of lower right leg

• Likely dermatome: L4

• Purpose: To localize the lesion depending on nerve roots involved.

Investigation of Choice (IOC): 

• MRI.

Treatment:

• Acute case: 
• Rest in Semi-Fowler position.

• Physiotherapy.

• Surgery: 
• Disc decompression
• If no improvement/worsening of symptoms
• Laminectomy.
• Laminotomy.
• Discectomy.
• NOT LAMINOPLASTY

Cauda Equina Syndrome

• Definition: 
• Massive disc prolapse
• leading to multiple nerve root compression.

• Clinical Features:
• History of backpain for over 10 days
• Bowel and bladder involvement (⊕).
• Saddle anaesthesia.
• Absent Knee and ankle reflexes

• Management: 
• Emergency decompression.

Lumbar Canal Stenosis / Neurogenic Claudication

Pathology: 

• Elderly

• Degeneration of spine

• Osteophyte proliferation around joint

• Stenosis

Clinical Features:

• Back pain radiating to lower limbs in an elderly patient.

• Neurogenic claudication:
• Pain on walking → Rest (Pain ↓) → Able to walk.

Pain:

• Worse on extension (Walking, standing upright).

• Better on flexion (Sitting/leaning forward).

Neurogenic vs. Vascular Claudication

Spondylosis, Spondylolysis, Spondylolisthesis, and Spondyloptosis

Spondylosis:

• Degenerative changes in spine, desiccated disc, disc bulge.
• Best seen on MRI.

Spondylolysis:

• Definition: 
• Pars intra-articularis fracture.
• between superior and inferior articular facet.

• X-ray sign: 
• 'Scottish terrier with a collar' sign.

Spondylolisthesis:

• Definition: 
• Slipping of one vertebra over the other.

• Most Common (m/c) location: 
• L5-S1.
• Mnemonic: SLip → SL → L5 S1

• X-ray / Palpable sign: 
• Step sign.
• Beheaded Scottish terrier

Spondyloptosis:

• Definition: 
• Listhesis beyond the length of the vertebral body.

• X-ray sign: 
• Inverted Napoleon hat sign.
• Stage 5 spondylolisthesis

Scoliosis

Definition: 

• Lateral deviation of spine >10° from central axis.

Note:

• If lateral curve of spine is < 10 degrees
• ⇒ Known as Spinal asymmetry.

Classification: 

• Structural or Non-structural
• Differentiated by Adam's forward bending test
• Structural/Fixed:
• Scoliosis persists on bending forward.
• Non-structural/Postural: 
• Scoliosis disappears on bending forward.

Evaluation: 

• Measurement of Cobb's angle.

Types of Structural Scoliosis:

Idiopathic (m/c):

• No visible anomaly on X-ray.

• Females > Males.

• Subtypes: 
• adolescent (m/c).
• Infantile,
• juvenile

Congenital:

• Anomalies present on X-ray.

Subtypes:

1. Failure of formation:
• Hemivertebrae is m/c
• Semi segmented
• Fully segmented
• Wedge vertebrae

2. Failure of segmentation:
• Block vertebrae
• Unsegmented bar
• Unsegmented bar with hemivertebrae

3. Mixed

Treatment:

Braces: 

• Prevents progression of deformity.







• Milwaukee brace.
• Walking like brace

• Boston brace.
• straight solid brace
• Charleston brace.
• Curved solid brace

Note: 

Taylor's brace



 


• used in thoracic spine injury & TB.

Surgery:

• For severe abnormality/inadequate correction.

• Rods and screws used.
• Screws inserted into pedicle.
• Harrington rods connect the screws.