Adrian Badila, MD, PhD

1. Traumas of the Vertebral Column

2. Diformities of the Vertebral Column

Scoliosis
Kyphosis

3. Disc hernia
 Traumas of the
Vertebral Column
ANATOMY
ANATOMY
Topographical classification

Superior cervical column ( C1-C2 )

Inferior cervical column ( C3-C7 )
 Superior cervical column
ATLAS AXIS
Inferior cervical column
 25° Cervical

Position of the
articular processes
60° Thoracal

90° Lumbar
 Biomechanics of trauma
DENIS - Theory of the 3 columns
Fractures of ATLAS

Comminutive fracture with

separation of the lateral masses
( Jefferson )
Fractures of ATLAS

Fracture of both
arches with separation
of one lateral mass
Fractures of ATLAS
Lesions of the transverse
ligament of the atlas
 Fractures of AXIS

Fractures of the odontoid process

Fractures of the C2 pedicle

Fractures of AXIS
Fractures of the
odontoid
process

Classification of
Anderson and
D’Alonzo
 Fractures of odontoid process
Classification Anderson and D’Alonzo

type I
rare
fracture of the upper part of the odontoid peg
above the level of the transverse band of the cruciform
ligament
usually considered stable
type II
most common
fracture at the base of the odontoid
below the level of the transverse band of the cruciform
ligament
unstable
high risk of non-union
type III
through the odontoid and into the lateral masses of C2
relatively stable if not excessively displaced
best prognosis for healing because of the larger surface
area of the fracture
 Displacement of odontoid process in fractures

P A P A
 Atlanto-axial dislocation
Atlanto-axial joint is the junction between neck and skull
The spinal cord is least reinforced in neck compared to thorax and abdomen.

Atlanto-axial dislocation
Ligament can cause severe spinal cord compression resulting in
significant neurological
transverse
injuries of upper spinal cord and lower medulla
Membrane
oblongata
Ligament occipito-
= life-threatening complications
atlanto-
axoïdien occipitale ant.

Patient may suffer paralysis of all 4 extremities (quadriplegia).

Fractures of the C2 (axis) pedicle
 Fractures of the C2 pedicle
Effendi Classification

Traumatic Spondylolisthesis
Spondylolisthesis is the slippage or displacement of
one vertebra compared to another.
Fractures of C3-C7 vertebras

Can involve:
Anterior column
Middle column
Posterior column
 Fractures of anterior column C3-C7
Unstable = Loss of
>25% of the anterior
height of the vertebral
body
 Fractures of middle column C3-C7
Unstable = Loss of >25% of
the posterior height of the
vertebral body
Widening of the vertebral
pedicles
Fractures of posterior column C3-C7
- Fracture of articular
processes
- Fracture of the
vertebral laminas
(arches) and pedicles
 Mechanisms
Causes
1. Car accidents
2. Sport accidents (ex.diving/jumping in a shallow water)
Primary mechanisms
1. Hiperflexion
2. Hiperextension
3. Lateral flexion
4. Axial compression
5. Rotation
 Clinical examination
1. Impossibility to voluntarly move the neck
2. Pain at mobilization of neck.
3. DON’T TEST THE PASSIVE MOBILITY OF NECK!!!
4. Vicious position of the head (ex. torticollis)
5. Contracture of neck’s muscles
6. Bruises, skin lesions or hematomas at the level of head, neck,
face, shoulders, etc.
7. Test the motility and sensibility of the limbs
8. Sustained penile erection (loss of sympathetic input to the
pelvic vasculature resulting in uncontrolled arterial inflow into
the penis)
 Radiological examination
1. Standard examination : antero-
posterior, lateral and 3/4.
2. Antero-posterior open mouth x-ray
view
3. Swimmer’s view - oblique view
which projects the humeral heads
away from the C-spine
4. Dynamic x-ray views under traction
 Radiological examination
Open mouth view
 Radiological examination
Swimmer’s view
Rx. C1-C2

Transbucală Profil
Rx. C1-C7
 Imagistical examination
1. CT –Scan 2. MRI
Neurological complications
1. Lesions of spinal nerves
2. Incomplete lesions of the spinal cord
3. Brown-Sequard syndrome
4. Central cord syndrome
5. Anterior cord syndrome
6. Posterior cord syndrome
7. Complete lesions of the spinal cord
 Neurological complications
Brown-Sequard syndrome
- caused by damage to one half of the spinal cord, resulting in
• paralysis and loss of proprioception on the same (or ipsilateral) side as
the injury or lesion
• loss of pain and temperature sensation on the opposite (or contralateral)
side as the lesion
Central cord syndrome
- is the most common form of cervical spinal cord injury
- It is characterized by loss of motion and sensation in arms and hands.
Anterior cord syndrome
- lower extremity affected more than upper extremity
- Loss motor function, pain and temperature sensibility
- Preserved - proprioception, vibratory sense
Posterior cord syndrome
- very rare
- loss - proprioception
- preserved – motor function, pain and light touch sensibility
Cervical sprains  Injury to the ligaments in the neck

 Treatment
 Schantz collar
 Pain relievers
 Muscle relaxants
 Ice pack for the first days
 Moist heat afterwards
 Exercises
 Physical therapy
 Treatment of cervical fractures

Orthopedic treatment
Indicated in fractures without
displacement or stable fractures with
minimal displacement
Minerva cast or orthosis
Surgical treatment

Osteosynthesis of
lateral masses

C1 = Atlas
Surgical treatment
Osteosynthesis of odontoid process

C2 = Axis
Treatment of atlanto-axial dislocation
Ancorare cu sârmăWiring

C1

C2
Treatment of atlanto-axial dislocation

C1-C2 arthrodesis (fusion)

 Surgical treatment
Anterior fusion with autograft

C3-C7
 Surgical treatment
Anterior rachisynthesis with plate and screws

C3-C7
 Surgical treatment
Posterior rachisynthesis with segmental instrumentation

Transpedicular screws

Rods

Connectors

C3-C7
 Surgical treatment

Osteosynthesis
with wires at the
level of articular
processes

C3-C7
 Surgical treatment
Reduction and fixation with laminar hooks

C3-C7
 FRACTURES OF THE
THORACO-LUMBAR SPINE
 Fractures of the thoraco-lumbar
spine
CLASSIFICATION
1. Fractures by anterior compression.

2. Explosive (comminutive) fractures of the vertebral body

3. Flexion distraction traumas (seat belt).

4. Fracture-dislocation.
Fractures by anterior compression
 Explosive (comminutive)
fractures of the vertebral body
Flexion distraction traumas

Seat belt mechanism (hiperflexion)

Fracture-dislocation
 Etiology

1. Car accidents
2. Sport accidents
3. Mine or building crashes (earthquakes)
4. Falling from height
5. Falling from the same level (osteoporosis).
 Clinical examination
1. Conscious or comatous
2. Diformities, bruises, ecchymosis, hematomas
3. Palpation of the spinous processes
4. Pain – spontaneous and at percution
5. Peripheral sensibility and motility should be tested
6. Neurological examination
7. Frequently – patient - politrauma
Imagistical examination

1. Radiology
2. Mielography
3. CT scan
4. MRI
Treatment of fractures of the
thoraco-lumbar spine

A. Orthopaedic
B. Surgical
Fractures by anterior compression
Orthopedic treatment
No displacement or minimal displacement
Immobilization in orthosis or cast – 6-8 weeks
Fractures by anterior compression
Orthopedic treatment
Compression <50%

Rest in bed with pillow to sustain the lumbar lordosis 4-10 weeks

Tonifierea musculaturii
 Fractures by anterior compression
Orthopedic treatment

Directions of compression in order to reduce the fracture

Corset gipsat
and reestablish cu curves
the normal 3 puncte de sprijin spine
of the thoraco-lumbar
(thoracal kyphosis, lumbar lordosis)

Reduction 1
 Fractures by anterior compression
Orthopedic treatment

Compression > 50%

Reduction = axial traction and forced extension of the lumbar spine

Reduction 2
 Fractures by anterior compression

Orthopedic treatment
Reduction in hyperextension by reclination

Reduction 3
Fractures by anterior compression
Orthopedic treatment
Cast
Corset immobilization
gipsat în reclinaţieafter reduction
6-10 weeks
 Fractures by anterior compression
Surgical treatment
Indication
Unstable fracture
Compression >50% of vertebral body height
Kyphosis > 20 degrees

Superior thoracal fractures

Posterior rachisynthesis (osteosynthesis of the
vertebral column)
Explosive (comminutive) fractures
of the vertebral body
Surgical treatment
Indications
1. Neurological complication
2. Compression of the vertebral body
>50%.
3. Angulation >20 degrees
4. Narrowing of the medullary canal
>50%.
5. Scoliosis >10 degrees
 Myelic fractures

Injuries of the spine with spinal cord involvement

 Surgical treatment

HARRINGTON
Instrumentation
 Surgical treatment

Posterior osteosynthesis with plates

 Surgical treatment

Anterior vertebroplasty with bone graft

 Surgical treatment

Vertebroplasty with acrilic cement

Specially formulated acrylic bone cement is injected under
pressure directly into the fractured vertebra, filling the
spaces within the bone - with the goal of creating a type of
internal cast (a cast within the vertebra) to stabilize the
vertebral bone.
 Surgical treatment

Osteosinteză transpediculară Cotrel-Dubousset

Segmental transpedicular instrumentation
 Surgical treatment

Segmental transpedicular
instrumentation
 Scoliosis
sideways curve of the vertebral column

S- or C-shaped
Associates vertebral rotation
In severe cases it can interfere with breathing
Scoliosis can result in a gibbus
Gibbus deformity is a form of structural kyphosis
typically found in the upper lumbar and lower
thoracic vertebrae, where one or more adjacent
vertebrae become wedged.
Gibbus deformity most often develops in young
children as a result of spinal tuberculosis and is the
result of collapse of vertebral bodies.
 Clinical examination
Symptoms
Back pain
Visible prominence
Functional impotence
Limited mobility
Breathing problems

Examination
Height measurement
Gait check
Foot shape
Skin inspection
Assessment of pubertal development
Neurological examination, including motor, sensory and
reflex tests (including abdominal)
Symmetry of shoulders and iliac crest
Forward bending test
 Clinical examination
Marfan syndrome
Scoliosis
Tall patients with long fingers
Increased arm span to height ratio
Cardiac abnormalities

Ehlers-Danlos syndrome
Scoliosis
Joint and skin hyperlaxity
Genetic disease of the connective tissue

Charcot-Marie-Tooth disease
Scoliosis
High-arched or cavus feet
Hereditary motor and sensory neuropathies characterized by progressive loss
of muscle tissue and touch sensation across various parts of the body

Neurofibromatosis
Scoliosis
Skin inspection that notes café-au-lait spots or axillary freckles
Benign tumors of the nervous system
 Curves measurements

Scoliosis = angulation > 10 degrees

X-rays of the entire spine in stand up position
The Cobb angle is used on x-ray to measure the angle between the most angulated
vertebras
The biggest curve is used to determine if the scoliosis is
- COBB- VERTEBRELE
dextroconvexe NEUTRE
(apex to the right)
- levoconvexe (apex to the left)
Dextroconvexe Dextroconvexe Levoconvexe Levoconvexe
Mild – 10-25 degrees
Moderate – 26-40 degrees
Severe – above 40 degrees
Treatment

TRATAMENT ORTOPEDIC- CORSET CU “3 PUNCTE”

Cobb angle
< 25 degrees – Kynetotherapy and periodical check-ups
25-40 degrees – Bracing till end of growing
40 degrees < - Surgery – segmentar instrumentation
Segmentar instrumentation
Kyphosis
 Kyphosis
 The spine has two kyphotic curves and two lordotic
curves which alternate to create an “S” like shape.
 Normal thoracic kyphosis = 20° - 40°
 Kyphosis
 Postural
The most common form of kyphosis is from poor
posture. Patients with postural kyphosis can
conscientiously correct the curve by standing up
straight.
 Structural
Structural kyphosis refers to an increased curve of the
spine not related to posture or slouching. Patients with
structural kyphosis cannot consciously straighten the
spine.
 Scheuermann's juvenile kyphosis
 most common type of structural kyphosis
 commonly diagnosed between the ages of 12 to 14 years
of age
 thoracic kyphosis measuring more than 40° with
wedging of three or more vertebrae in a row
 cause is unknown (probably abnormal bone growth
and development) - genetic predisposition
 CT scan or MRI - Schmorl's nodes = small disc
herniations through the endplates of the vertebra
Scheuermann's juvenile kyphosis
 Kyphosis - treatment
 Mild forms – no treatment
 Pain or stiffness from their kyphosis
 Physical therapy
 Kinethoterapy
 Severe cases or curves that progress
 Bracing for patients still growing
 >80-90 degrees of thoracic kyphosis
>60-70 degrees of lumbar kyphosis
 Surgical treatment –
segmental instrumentation
 Kyphosis - Ankylosing spondylitis
 Ankylosing spondylitis is a type of arthritis that
affects the spine and the sacro-iliac joints
 Symptoms - pain and stiffness from the neck down to
the lower back, pain in ligaments and tendons
 The vertebrae fuse together, resulting in a rigid spine.
 Most often strikes men in their teens and 20s
 Kyphosis - Ankylosing spondylitis
 HLA B-27 antigene
 90-95% of patients with AS
 8% in general population
 Bamboo spine - result of vertebral body fusion by
marginal syndesmophytes
 Kyphosis – Pott’s disease
 Tuberculosis of the vertebral column
= tuberculous spondylitis
 most commonly localized in the thoracic portion of the
spine
 In a process called caseous necrosis the disc tissue dies
leading to vertebral narrowing and eventually to vertebral
collapse and spinal damage
DISC HERNIA
 Disc hernia

Intervertebral discs consist of an outer fibrous ring, the anulus fibrosus disci
intervertebralis, which surrounds an inner gel-like center, the nucleus pulposus
 Clinical examination
 Symptoms
 Pain – can irradiate in a nerve territory
 Functional impotence
 Limited mobility
 Antalgic position
 Clinical examination
 Muscle strength tests
 Sensory testing
 Deep tendon reflexes (knee and ankle jerk)
 Lying straight-leg test (Lasegue)
 Sitting straight-leg test
 Femoral stretch test
 Clinical examination
 Lying straight-leg test (Lasegue)
 Patient lies on his back with both legs extended. The doctor will raise the
affected leg toward the patient’s head. A positive test for herniated disc
produces pain down the back of the leg, below the knee, when the leg is
raised up.

 Sitting straight-leg test

 The patients sits on the exam table with both knees hanging over the edge
of the table, bent at 90 degrees. The examiner will slowly extend one leg
until the knee is straight. A positive test for herniated disc produces pain
down the back of the leg, below the knee, when the leg is raised.
 Clinical examination
 Femoral stretch test
 The patient lies face down on the exam table with the legs
extended. The doctor will raise one leg toward the ceiling and
then bend his knee. The test is positive if it produces pain that
radiates toward the front of the thigh
Clinical examination

Scoliotic position Lasegue test

Territory of L4
Sensibility area in green – hypoesthesia / anesthesia
Patellar deep tendon reflex is decreased/absent
Ankle dorsi-flexion – decreased / absent
 Sensibility area - hypoesthesia / anesthesia
Territory of L5 Biceps femoris deep tendon reflex -decreased/absent
Great toe extension - decreased/absent
Territory of S1

Sensibility area - hypoesthesia / anesthesia

Achilles deep tendon reflex - decreased/absent
Ankle plantar-flexion/ankle eversion/hip extension - decreased/absent
Deep tendon reflexes and their correspondent nerve roots
 Myelography

Myelography uses a real-time form of x-ray called fluoroscopy and an injection of contrast
material to evaluate the spinal cord, nerve roots and spinal lining (meninges).

Useful for:
assessing the spine following surgery
assessing disc abnormalities in patients who cannot undergo MRI
CT scan

Spinal Hernia
cord
MRI – Golden standard
Hernia

Hernia

Hernia
Hernia
 Treatment

 Medical treatment

 Chemonucleolysis

 Surgical discectomy
 Medical treatment

 Rest
 Painkillers
 Painkillers for neuropathic pain (pregabalin,
gabapentin)
 Nonsteroidal anti-inflammatory drugs
 Muscle relaxants
 Physical therapy
 Kinetotherapy

 Epidural steroid injections - corticosteroids,

= potent anti-inflammatory agents that quickly
relieve pain caused by compressed nerves
 Chemonucleolysis
 non-surgical treatment for
a herniated disc that involves the
injection of an enzyme into the
vertebral disc with the goal of
dissolving the inner part of the disc,
the nucleus pulposus.

 The procedure uses chymopapain,

an enzyme from the papaya fruit, to
dissolve the displaced disc material
that is putting pressure on the spinal
nerve.
 Surgical discectomy
• surgical removal of herniated
disc material that presses on a nerve
root or the spinal cord

• laminotomy is often involved to

permit access to the intervertebral
disc = the lamina is removed from
the affected vertebra

Modern techniques:
Microdiscectomy
Endoscopic discectomy
Laser discectomy
 Percutaneous nucleotomy

minimally invasive procedure involving the removal of the inner material of

a herniated disc that has compressed a nerve root or the spinal cord
Spina deformities

Spine trauma FINAL

Disc hernia