Hi, welcome back. We're with Dr. Prasad for Spinal Cord Injury Evaluation and Management. He's Associate Professor of Neurological and Orthopedic Surgery at Thomas Jefferson University, specializing in complex spine and peripheral nerve surgery. He grew up in Chicago, Illinois, completed college and medical school at Boston University. He graduated and completed a surgical internship at John Hopkins and has an MS in Surgical Robotics from the John Hopkins University. He also completed residency in Washington University of St. Louis, has a fellowship in complex spine and peripheral nerve surgery at the Cleveland Clinic, and is faculty currently at Thomas Jefferson since 2009. He has particular interest in spinal oncology, spinal deformity, and surgical robotics. He enjoys woodworking, all things related to cars, and is a weak but aspiring golfer. He also enjoys spending time with his wife and his six-year-old twins, but they're growing up too fast. I understand you there. Okay, thank you, Dr. Prasad, for being with us today. Enjoy the lecture. Hello? Yeah, great. Thank you. Can you guys hear me okay? My screen randomly froze right at the wrong time there. Thanks very much for that kind introduction, Alice. My name is Srini Prasad. I appreciate you guys inviting me for this. I'm one of the spine faculty at Jefferson, as she was just saying. So today's topic is going to be spinal cord injury evaluation and management, and in making this talk, it's obviously a broad space, but I tried to kind of organize it as best I could. So without further ado, I'll kind of go forward. So none of my financial disclosures are pertinent to this talk, but they're listed there. So we'll start with the polling questions. Which of these ASIA scores represents a worse neurological exam? Option A is an ASIA score of B. Option B is an ASIA score of D. Yeah, so we're rolling in the results right now. We're about 5941 ASIA B over ASIA D. Kind of equalizing a little bit, but we're still hanging in with more ASIA B than ASIA D, but we're at about 58 and 42 percent. Over half the respondents. I think we're there. 58 percent ASIA B, 42 percent ASIA D. Great. So we'll get into that when we move forward. But it's interesting that it's split, because it's obviously just one of them. Can I start with the second one? So the polling question number two, which of these is the least favorable time for surgical intervention for a central cord syndrome? Three days after the injury, three weeks after the injury, or eight weeks after the injury? They're rolling in. Cool. So we're currently at 76 percent eight weeks, 20 percent three days, and nine percent three weeks. Cool. Is that enough respondents? Can we move on? Let's wait a little bit longer, although I think that eight weeks is going to win out. Yeah, let's go with it. Sixty-four percent eight weeks, 29 percent three days, and seven percent three weeks. Okay, perfect. Perfect. We'll get to that too. We'll cover these just in the body of the talk. And then the last question, which of these injuries has the lowest rate of neurological injury? Atlantal occipital dislocation, type 2 odontoid fracture, unilateral cervical facet dislocation, or bilateral cervical facet dislocation? Okay, 67 percent unilateral. No, we're going about 50-50 now. About 50-50 type 2 odontoid and unilateral cervical facet dislocation. We're at like five and four percent atlantal occipital and bilateral cervical facet. Okay, that's great. That's great. So topics we'll kind of cover when we go through it. So I'm going to move on. We'll do a case example just to kind of highlight a couple of these. This is a 60-year-old gentleman on a motorcycle accident came into the emergency department as a C6 Asia A. No motor or sensation below the level, no rectal tone, sensation, or voluntary contraction. His injury happened at 7 p.m. on a Friday night. And here you can see that he has a fracture dislocation. It's a C4-5 dislocation with pretty severe spinal cord compression. When you look at the CT scan, you can see that, excuse me, I'm sorry, it was a C5-6. You can see that he has a fairly significant disruption of his joints unilaterally. The scenario kind of summary is unilateral locked facet. And the question really about it is like, when do you do surgery for it? What's the best approach for this? Do you do something from the front? Do you do something from the back? Like how would you approach this? And understandably, these are controversies. We're not going to get deep into them, but we'll talk a little bit about the options. And then how many levels would you do? You know, are you going three up, three down, two up, two down, that kind of thing? And then what's the role of traction? This person comes in on 7 p.m. on a Friday. Are you reducing them? Are you taking them straight to OR? Like all that stuff is stuff that is controversial, but understanding the decision-making around that is part of the purpose of this talk. So we're going to talk a little bit about spinal anatomy. I know you guys had a nice talk on it, so I will not belabor it out of interest in time. We'll talk about spinal cord injury epidemiology. And then it's important to kind of recognize that you can't really tease apart spinal cord injuries from spinal column injuries, that there often is some type of spinal column pathology. And so we have to talk about fracture patterns, in a sense, and associated spinal cord injuries with them. So we'll try to cover all of that stuff in the next 30 minutes or so. So I won't talk much about this. It's important to recognize really principally that the spinal column and the neural elements are the two different components that are important in spine anatomy. The spinal column, of course, you've talked about 24 bones, three different areas, cervical, thoracic, and lumbar. It's a lot to cover in a spinal cord injury talk. We'll kind of talk a little bit about some of the main ones. And then the neural elements, of course, there's spinal cord and spinal nerve. And I know that you guys know that, but spinal cord stuff starts at the level of the occipital cervical junction, it goes down to around L1, and below that is just nerves. I use this analogy that your spinal cord is like a tree trunk, and the branches that come off of it are the spinal nerves. So that's useful in explaining to patients as well. An injury to the trunk can kill the tree, an injury to the branch will kind of affect that branch alone. The spinal column itself, just to review it, there are different components. The vertebral bodies themselves represent the anterior or the front part of the spine at each segment. There are 24 segments, I kind of skipped over that slide. The pedicles unite the vertebral body to the structures in the back. So this is considered the posterior arch, this is the vertebral body. And we'll talk a little bit about the column model, but when we think about the spine, you have to think first about the bodies, then you have to think about the fact that there are ligaments that unite them and discs between them. So between the discs, ligaments kind of uniting all these, it's a compliant pliable structure that is designed to protect the spinal cord and the spinal nerves that run right down the center of them, as you can see kind of in this middle image right there. So that kind of intimate relationship between the spinal cord, spinal nerves, the bones, and the ligaments that unite them is really important to understand when we think about trauma and the relationship between a bony fracture, a ligament injury, and the nerves or the spinal cord that can be affected by that. So spinal alignment, just to kind of talk a little bit about this, so the terms are familiar with you, lordosis is the idea of curvature backwards, so that's the cervical and the lumbar spine are typically lordotic. Kyphosis is curvature forward, and that's normal in the thoracic spine. Life is kyphogenic, as they say, over time everybody kind of falls forward. Aging, I should say, is kyphogenic, so it's important to kind of recognize global alignment and that helps establish what the goals are afterwards. But when you talk about deformity, it's important to kind of look at what normal is. So spinal alignment, when we think about it, we, you know, there can be local malalignment, so a lot of thoracic kyphosis or global malalignment, those are kind of important considerations, but really take-home message on this is that sagittal alignment is a really big deal for us. We think a lot about sagittal balance. Coronal balance is not as big a deal, so when people talk about alignment, really we care predominantly because that has the biggest impact on quality of life. So deformity begets deformity. When we're talking about how to treat these, and these are kind of basic principles in spine, but I think important for the discussion we're going to have. Deformity begets deformity, so like the leaning tower of Pisa, once it starts tipping, it wants to tip more. The more it tips, the more it wants to tip. The same applies to deformity. If somebody is fused kind of in kyphosis, you know, with forward flexion, then the tendency is for them to keep falling forward, and you get proximal problems and other problems with that. So when you think about spine anatomy, there are a few kind of regions to think about. One of the important areas to talk about, and I dedicated a slide to that, is the upper cervical spine, so the occipital-cervical junction. That's between the skull and C1 and C2. Most of your flexion and extension, like leaning forward and leaning back, comes just from the occiput to C1. It's pretty astonishing. You can't see it super well on this, but the articulation here is something that allows 50% of your range of motion right from there. So we have to think long and hard before fusing someone's skull to their neck because you lose a lot of motion. All the rest of your spine really gives you the other 50%. And then C1 and C2, 50% of your rotation comes from that. So this area is very important. It's also a little bit, it's extremely tightly bound in all of these ligaments, this transverse ligament, the cruciate ligament overall. There's a bunch of ligaments that form this complex to kind of bind all that together to permit movement, but in a constrained way. So fractures up here are not uncommon. We're going to talk a little bit about them kind of in sequence. We won't talk much about this just in interest of time, but the range of motion, as I had mentioned, it's kind of concentrated, kind of mid cervical spine. Most of it's at the top and the rest of it's like around C5-6. The thoracic spine is a little bit different. It's 12 vertebral bodies kind of in the middle of your spine. Probably the most important thing to know about it is that because of the ribs, you can think of it as a barrel. It's very stiff. It's hard to kind of fracture the thoracic spine, but if you see a thoracic spine fracture, you have to assume it's a much higher injury because it takes a lot to break a barrel. So think like when people have a high injury, a high energy injury, you have to think about all the concomitant injuries they can have with that. That's probably the single most important thing to think about. The other kind of important consequence of having a very rigid thoracic spine is that the junction between the neck and the thoracic spine is a very big inflection point, so people can have fractures at that junction. And then thoracolumbar fractures, which is the bottom of the thoracic spine, the top of the lumbar spine, another common place because there's, it's a concentration of energy. The barrel is kind of flying forward on the low lumbar spine, which is just a stack of blocks. So a lot of fractures will happen at the thoracolumbar junction. The energy in this, because it's kyphotic when people fall forward or have an injury where they have a flexion injury, kind of the mid thoracic spine can be affected, and that's what this is really designed to show. So understanding the anatomy, the mechanism of the injury will help kind of better understand what type of ligament injuries to look for, bony injuries to look for, and then help you determine what's stable and what's not stable. I won't talk much about that. So then skipping, that's just kind of a very brief overview of spinal anatomy as pertinent to this talk. So we'll get into spinal cord injury. It's something that you will definitely see as advanced practice providers in neurosurgery. It's bimodal in distribution, so what you can see here is really it's common in this 10 to 30 year range, and it's in all categories. We'll talk next about that, but obviously you think sports. That's a common cause of spinal cord injury in young people, and then you can see it kind of plateaus through middle age here, and then the elderly are also at risk of it, and it has to do with balance, and they're a little more fragile. Their bones are more fragile. There are a variety of reasons. So it's bimodal with most spinal cord injuries happening in the younger population. That's part of the burden of it. The economic and social burden of it is the fact that these are young, potentially productive people who can be severely impaired by a spinal cord injury. It's much more common in males, 82% male, 18% female, and then if you look at the different causes, and I'm not sure how well this projects on your screen, but motor vehicle accidents and blues, sports injuries, falls, violence, you can see that really the young population, this 15 to 18 to 30 range really dominates the incidence of it for all of those different categories of injury. Now the Franco classification or the ASIA score, which is the American Spinal Injury Association, is graded A through E. So I use this simple, when I was a medical student, I remember thinking like A is awful and E is excellent, and then everything in between kind of falls in between. So you can think A is awful. So an ASIA-A spinal cord injury like that case I presented is awful. No motor, no sensory, an ASIA-A spinal cord injury is a complete spinal cord injury. An ASIA-B spinal cord injury, and it's important to keep reviewing this because it's tough to remember, but ASIA-B is only sensory function. ASIA-C and D we'll talk about in one second. ASIA-E is an intact person. So what are C and D? C and D, people with an ASIA-C or D spinal cord injury have motor function and it's below a certain level. So people will say it's a C6 ASIA-C. What that would imply is that if you look at all the motor groups from C6 down, it's either less than 50% for an ASIA-C, less than 50% of them are anti-gravity or for an ASIA-D more than 50% are anti-gravity. But think C and D there's some preservation of motion where in D there's more motion preservation and C there's less. B there is no preservation of motor, but there is a preservation of sensation. That's a big difference, right? For somebody's spinal cord to be completely severed, if you think it's completely injured, everything is gone. But if there's some preservation of sensation, there may be some continuity of the spinal cord and maybe a bit more promise. And in fact, the prognosis for a B versus an A is pretty significantly different with B being better. So A is awful, E is excellent, kind of remember that. And then you can kind of derive the ones in between, but review it. I think it's useful in relaying to people how bad an injury is. So the injury cascade, my motorcycle injury patient that I presented at the beginning, right? He gets a motorcycle injury and there's an acute deposit of energy into his spine and spinal cord and he fractures his ligaments. Here he has a fracture dislocation. This disc is disrupted at C4-5. He's got severe edema within the spinal cord with spinal cord compression. That injury happened. That's the primary injury. That's what happened when he was on the street. What happens afterwards though is the cascade of events where the spinal cord here is quite vulnerable. So it's very susceptible to low blood pressure, to hypoxemia. So it's vulnerable like any other injury. And so you want to prevent secondary injury. Our interest in managing these patients is to minimize the secondary injury. There is no way to address the primary injury or undo the primary injury. It's to minimize all of the things that can have a negative effect on the spinal cord's ability to recover. So that would include like, let's restore alignment. Let's take the pressure off the spinal cord. Let's maintain high blood pressure. Let's use, for example, it used to be steroids. That's a controversial, more or less discounted. Nobody does that now, but there are all these things. But imagine what we're trying to do is minimize the secondary injury. So that's an important point to talk about as we go through this. So what are the general management? High level, all spinal cord injuries. You get called about a spinal cord injury. It's of course, prompt immobilization of that area. Hemodynamic stabilization. This is generic kind of ABCs. And this, I mean, even goes before immobilization, but the ABCs are always kind of a primary importance. Prompt immobilization is central. And that means backboard. That means collar. That means whatever area of interest or concern you have, that's an important thing to prevent further injury from happening. A detailed, and then you want to make sure you scan and stabilize other injuries as well. So there's not like a significant blood loss happening somewhere else that will have a negative effect also on the spinal cord. Detailed neurological assessment as soon as the patient is stable. So once the ABCs are done, D is really an evaluation of the neurological status. It's a big deal to maintain spinal cord perfusion. And that, you know, for a whole bunch of reasons, but the imagine it is basically saying we like to keep the blood pressure high in patients with spinal cord injury. Now, again, they're younger people. They can tolerate it, right? Especially that population. The 85 year old, you worry a little bit more. Also what's the normal blood pressure for this 85 year old? Could be 160 over a hundred. I mean, you don't know what their normal is, but the idea is you don't want to see them hypotensive. That much is for sure. So trying to maintain blood pressure support is a big part of what we do. And the guidelines form suggests five days. So usually people are in the ICU, A-line, MAP support, on pressers potentially offer up to five days. So it's kind of a big deal, but these are general kind of principles for any spinal cord injury. And then steroids have largely been discounted. When I was a resident and a fellow, it was still kind of controversial. There were three different studies looking at it. I won't get into it, but the bottom line is the guidelines from the CNS now are that steroids are not indicated in the setting of a spinal cord injury. We generally do not stop it if somebody else has started it. So just so you've heard, like I wouldn't take somebody off of a solument roll, but I would not start them if it's up to you. So what's the routine? Before we get into the specifics of specific type of fractural morphology, what's the routine workup? First, the important thing to know is like, what's the responsibility? What are the functions of the spinal column? The spinal column is designed to do achieve a couple of things, help you maintain an upright posture and protect the nervous system. So it protects the spinal cord, protects the spinal nerves, helps you support the head or maintain an upright posture. One analogy that's useful to think about with this picture is that we think of the front part of the spine as being a stack of blocks. So it's responsible for axial load bearing. That means like if you put a load across my head and go downwards, what bears that load is the stack of blocks, one on top of the other. So if you have a burst fracture or compression fracture, it's important to kind of think about where it is and the impact of axial loading if that body is broken. The second thing to think about is that pliable, the spine is pliable. So because of that, we have to think that there are the ligaments that provide that flexibility. We think of the posterior aspect of the spine, we talked about the the lamina, the spinous processes and stuff, that we think of it as a tight rubber band, it's called the posterior tension band. The posterior tension band helps hold your spine upright. So if a disruption of the ligaments or the muscles or something like that that's significant in the posterior column will have an impact in that it can sometimes relax the back and people can kind of fall forward. So a fracture that involves the front and the back of the spine is potentially significantly more unstable than if it just involves the front of the spine. So thinking about ligament integrity is important in each of these fracture morphologies. So what is a stable spine, right? You'll hear people say the spine is stable, like what does stable mean? And that this is something, this is a good definition to kind of internalize. There is no such thing as like not all fractures of a certain type or not all burst fractures are stable or unstable. White and Punjabi long ago, 30 years ago now, described or defined stability to be the ability of the spine under normal physiologic loads to prevent initial or prevent additional neurological damage, pain, or deformity. So think of it as the ability of the spine to resist progressive deformity, neurological damage, and prevent gross deformity. That's the meaning of a stable spine. So if you say the spine is stable, you're making that assertion based on a lot of things, not just what the CT scan looks like, but the MRI, the x-rays, upright films, flexion extension views if that's appropriate. So I honestly don't even feel like we need to waste a lot of time. Like when I was in medical school and residency, like cervical spine x-rays were the standard. It's like everybody got them and these were the criteria for them. I think it's still important to kind of know them, but in practice most people get CT scans and MRIs and we'll talk a little bit about the data of that and why that is. But traditionally the thinking was if somebody comes into the ER without any neurological abnormalities, is not intoxicated or on any drugs or anything else, has no cervical spine pain, and has no other distracting injury that they don't even need an x-ray. So if they have good range of motion, no neck pain, they're neurologically intact, and they're not inebriated or intoxicated or something like that, then you can clear their cervical spine clinically. You don't need to get x-rays or any further imaging. That is probably the one useful thing to kind of take away from this slide in terms of when c-spine x-rays are relevant or not indicated. I won't talk about that. We will talk about CT scan because what's really changed is CT and MRI have become more or less the most pervasive studies that people get. A CT scan takes no time. A lot of time people will get a pan scan, so looking at their cervical spine or thoracolumbar spine in the context of that is done, like that's something that's fairly common. The important thing to recognize here is that a CT scan has a multi-plane multi-slice CT, so multi-detector scanner, has a sensitivity of 100% and a specificity of 99.5% amongst 600 and something trauma patients, where plane films had a sensitivity and specificity of 45 and 97. So there's almost no comparison. Nobody makes real clinical decisions anymore when they're concerned about a spine injury based on x-rays, and this is part of the reason why. MRI scan is another very useful thing, and you guys may know this, especially after the lecture you had on imaging, but an MRI scan is very useful for looking at the neurological elements, for looking at soft tissue structures like discs, and for looking at the ligamentous structures that kind of hold everything together. So you can see edema, you can see discs, like this arrow here kind of points to discs based, or I'm sorry, interspinous and supraspinous ligament disruptions of the posterior tension band being gone, and you can see the injury to the spinal cord here. So I won't talk a lot about it except to say that when you look at these plane x-rays and palpation, like a step off. I mean, the numbers for sensitivity and specificity are not that great. MRI scan is very good for detecting these injuries. So it's still not perfect, but very good. So we'll change gears a little bit to get into the spine trauma injury patterns and management. And I will go through them a little bit quickly and kind of weave them together so I leave some time for questions as well. The management principles, number one, as I said before, we're trying to prevent secondary injury. So what we tell people is we're trying to maximize your chances of a neurological recovery, prevent any decline, neurological decline, and to prevent deformity or progressive deformity afterwards. Ideally, you'd like to minimize pain as well or maximize pain relief as well. There's three types of instability. There's mechanical instability, neurological instability, and both mechanical instability, we talked a little bit about before. Neurological instability is when people have progressive neurological decline or that there is an inability to protect the spinal cord and spinal nerve. So the non-operative treatment, general principles for that. You have a question, Alice, or you just- Yeah, so we have a few questions. Do you use steroids for spinal cord injury? This APP works with a physician who still does. Yeah, I mean, so what's interesting is that's controversial for sure. That's a great question. I don't think that it would be indefensible either way. And what I mean by that is that Michael Falings, for example, is a well-known neurosurgeon in Toronto. He has this very interesting argument that the guidelines went from it being kind of recommended, but an option in the previous CNS guidelines to now being recommended against and the data never changed. And the question is like, well, what data is that predicated on that we can kind of launch as a whole society this new kind of recommendation against it? The thinking on it is that the reason it became controversial is primarily that, I mean, my sense is it became a bit of a tinderbox from a medical legal standpoint. You did do it, you didn't do it. That became a bit of an issue. The other thing is that there were a fair number of collateral consequences to using steroids. They're not benign. People had higher rates of pulmonary infection. So as a rule, like we're at a fairly busy trauma center and we do not, most trauma centers that I know of do not use it at this point. It may take a little while to catch on, but that's changing. The culture of it is changing, although the data hasn't really changed. How long post spinal cord injury will you maintain an increased BP? As a rule, we typically keep MAP above 85 for a week. Any thoughts on that? That's the guidelines are, and honestly, most people do five days. And in the ICU, four or five days with an arterial line in somebody who's requiring pressors. Now, sometimes you get these older people whose blood pressure runs pretty high. We do use the same goal, 85 millimeters of mercury MAP. So people with a wide pulse pressure, for example, that can be a challenge. If people need pressors, they stay in the ICU for five days. If they are fine, like, I mean, if their blood pressure, they're maintaining it on their own and they don't need anything for it, then sometimes we'll move them out of the ICU, but we still want to maintain their MAPs and we're sensitive to their blood pressure for five days afterwards. So we had a few questions about MAP. So those, I think you answered. What type of ligamentous injuries in the C-spine do you consider unstable requiring a collar? So yeah, the collar thing and the instability. In general, discal ligamentous disruption, if you get isolated soft tissue disruption, so ligamentous disruption, it's really only like extension distraction injury or like a flexion. For the most part, there'll be a bony injury with it, but an extension distraction injury is considered a fairly unstable. The other ones we'll kind of get into, like flexion distractions or a fracture dislocation of some sort has a lot of ligamentous but bony injuries as well. Now, it used to be a long time ago, like a small tear drop fracture on an x-ray I mean, like you look at it, it looks like a little chip. Those were thought to be unstable and put people in a collar for them or even surgery for them because it was assumed there was a lot of discal ligamentous, which means disc and ligament disruption. But now with MRI scans, if we see a little chip fracture, but no disc or ligament disruption, we will treat it in a collar without anything surgical. If there is disc or ligament disruption, then it would typically be surgically managed. One more question about MAPs. Once weakness and numbness resolves, you can still complete the full five days. We do, yeah, we do. I mean, in a person who's completely intact, if you could argue to wean down the pressers and see how they do, but it's done with an end point of like following the neurological exam to make sure that they're tolerating it. But we generally tend to err on the side. Anybody who has any kind of a neurological deficit, we would watch for the full five days. I think I maybe understood the question a little late there. If somebody becomes neurologically intact, we will try to wean, we will do that. We'll wean down the pressers if it seems reasonable. Do you have a preferred presser? Not really. We have a neurocritical care unit and they manage all of that. Okay, I think we're good. We're good to go. Perfect. All right, cool. So general principles of non-operative treatment. Pre-hospital, of course, like stabilization. So like backboard, collars, other protective things. We talked a little bit about the ABCs and other things to do right off the bat. So immobilization, like, you know, this is what braces look like. And the principle, obviously you guys have seen collars, TLSOs, there's custom TLSOs, this one over here. All these people look so happy. None of our patients look that happy. They never fit that well. This is kind of what a normal brace actually looks like. It never looks like it's like made for them. So like you have to think braces have morbidity. People hate them. Like they're not fun to be in, but we use them quite frequently. We just have to be sensitive to the type of brace and make sure it's effective. So this is designed to kind of show that if you have a very short, let's say somebody has a mid thoracic fracture, you put them in a short fracture. It's not just about having, like covering the thoracic spine. The longer the fracture, the more, I mean, excuse me, the longer the brace, the more it resists kind of motion. So this is a big difference. This is an easy thing to kind of recognize. The short collar versus the collar that goes over the shoulders in front of the clavicle versus this. This is much more restrictive. Of course, this is like a cervical thoracic. So depending on where the injury is, if it's mid cervical, this could be fine. If it's cervical thoracic, you may want a brace that's a bit more like this. So think about where the injury is and the type of fracture and make sure that that seems rational to you when you're picking bracing. Now, whenever we do bracing, we get x-rays. I get x-rays right afterwards. Like, you know, so day one, day two, I don't get flexion extension films in a person with a fracture, but I would get x-rays as a baseline because you're going to then look at those x-rays in followup and that could be four weeks, eight weeks, whatever out, you know, depending on how long you want to manage them. But you're going to do at least one at the beginning and one at the end. So you can kind of see how much loss of lordosis or how much change in their alignment they've had with that. I also check incremental ones to make sure the brace is working. So you get one four weeks out and it looks like their alignment is preserved. You say, great, this was a good brace, et cetera. Halo vests. Again, this is what they look like in the model. This is what it looks like in reality. It's not, these are miserable. In elderly people, these are a death sentence because they can't look at their feet. So be really cautious. Not a lot of people are using halos anymore, I would say. So surgical treatment. Now there's cervical and lumbar, and I'll kind of cover, I'll try to cover it all in 10 minutes, but all of them, for the cervical spine, there's an anterior approach and a posterior approach. For the thoracolumbar spine, there's an anterior, which can often be lateral. So coming in from the side. So when we do a lateral approach, we will often call that anterior because it's anterior to the spinal cord. But so it's anterior to the spinal cord can be one of either these anterior or lateral. And then of course there's posterior approaches as well. And depending on the type of injury, we'll sometimes use both. And we'll kind of talk a little bit about that. So the factors that affect your choice of approach are a few. Number one is how much is disrupted. Is it the front of the spine and the back of the spine, or is it just the front? Is it just a disc? So like if somebody just has a disc disruption, you could argue to go in and just clean out the disc and put a spacer in and put a plate on it. But what columns are disrupted has an impact. As a general rule, the stability of instrumentation put in from the back, so posterior lateral mass screws or posterior pedicle screws, in general, those are stronger than anterior cervical instrumentation or anterior lumbar instrumentation. So again, posterior approaches are stronger as fixation than anterior plates. That's just a good thing to kind of put. So if you're very worried about someone's stability, the posterior is a bit stronger. Where's the compression? So if the pathology is on the front, like in this situation, you'd feel a little bit bad just decompressing from the back, but you certainly could. That's in fact probably what I would end up doing. But if the pathology, if there's a huge disc herniation in the front, you're going to go from the front, at least from the front and maybe both. Where is it? Upper cervical is tough. You can't really go to the front at C2, C1. You can, but it's like through the mouth or through the nose and it's involved. So in the upper cervical spine, we'll go typically from the back. Mid cervical spine, it's kind of dealer's choice. Low cervical thoracic, and like a short squat person with no neck, that's hard. So you end up going from the back as well. But where it is in the spine has an impact as well. And how many levels, of course, will have an impact as well. And then is there deformity? That's a big consideration. If you want to restore lordosis as a general rule, it's about making the front longer and the back shorter. So you can kind of pick one or the other, or sometimes do both to restore that. And then how unstable is it? This is an important point if you haven't heard this. Many people know this, but this is not intuitive. Instrumentation is put in on the day of surgery. That's this curve right here. And it only gets weaker. It never is as strong as the day you put it in. It makes sense, right? These people are moving, it gets a little loose, et cetera. The bone is the weakest the day of the surgery, because you've disrupted it, destabilized it, and then it gets stronger over time. So there's some crossing point here. And basically getting a fusion is a race between the hardware and the bone healing, which is why smokers with a slower rate, when people have hardware failure, rods break, screws break, it doesn't really matter if the fusion is solid. It becomes a problem if the fusion isn't solid, because that means that the instrument failed before the bone had a chance to fuse. So this is spinal cord injury awareness month, coincidentally enough. So we'll talk about common injury patterns and management. So at the atlanto-occipital dislocation, this is like where someone's head gets detached from their body. It's a big deal. This is an extremely unstable injury and an extremely fatal injury. Most people don't make it to the hospital when they have this injury, because your head is literally disconnected from your spinal column. So the AO dissociation is the extremely high rate of neurological injury. It's fairly rare to see an AO dissociation with somebody who has preserved neurological function. It can happen, but imagine it, like your spinal cord and some of the muscles are all that's holding this person's head on. It's wildly floppy. You know, think of like one of those bobble heads. That's like this injury. It's extremely unstable. The treatment for it is to basically attach their head again. So it's a posterior occipital cervical fusion. You put a plate on the back of the head and connect it up. So this is a very unstable injury. The next injuries we'll talk about are the C1 and C2 fractures. So C1 fracture, the common fracture there is a ring. It's an axial load. So if you imagine hitting me at the top of the head, the ring of C1 kind of fractures outwards. So you can see if you load it, this is a top down view, you load these two lateral masses here, the surface, the superior particular process of the C1 level, and it basically plows and these things kind of fly apart. Now, usually the ligaments are preserved with that. So the things are kind of loosely in place, fairly stable fracture. And it's something that we leave in a collar. We do not treat these surgically as a general rule. Odontoid fractures are another thing that's important to talk about. An odontoid fracture is a fracture of the C2 bone, particularly the odontoid process. So here you can kind of see it up here in this bony cadaver thing. Here you can see it. This is the odontoid process. This is C2, C1 sits right on top of that. It's a frequent fracture. It's 10 to 15% of all cervical fractures. The mechanism for it is more often flexion than extension, although you can have both. There is some estimated, I don't know if that, obviously you don't know who's not making it into the hospital. It's classified into type one, two, and three. And this is useful to know. Type one is just the tip. We'll talk a little bit more about them. Type one is just the tip. Type two is the one that's the most common. Type three is one that kind of really descends down. It's a fairly significant disruption of the vertebral body. It's very rare for C1 or C2 fractures to be associated with a neurological injury because the spinal canal is so big at that level. It gets small, especially with degenerative stuff later. So type one, and I don't want to belabor, it's super rare, it's very stable. People are managed primarily in a collar. Type two and ontoid fractures are the most common fractures in the elderly. It's the most common cervical fracture, I'm sorry, in people older than 65. These are generally, it's controversial how you manage these. And so many people will have, you know, will work with people that put them in a collar and just kind of follow them. Other people would do surgeries from the front. Other people do surgeries from the back early on. I tend to be at a center that does it early on. It's very controversial. There's not a right answer for how to manage them. And then top type three fractures that descend down through the vertebral body. Now, and it usually involves the surface of the joint itself. Now, what's interesting about these fractures is that even though they look like a more severe fracture, because there is so much cancellous bone around them, because it's like really involving the body itself and it's usually kind of healthy, bloody bone, they heal up great. And so we tend to put people with a type three fracture or a type one fracture in a collar. The type two fractures are where there's controversy about how to manage it. So one way to manage the type twos is like this with the screw that goes up from the bottom. You can kind of see the screw right here. This is kind of showing it in an illustration. And the other way to do it is to do a C1-2 where you fuse C1 and C2. So obviously the problem with that is that you lose 50% of your ability to turn your head. I wanna give guys a chance for some other questions. So I'm just gonna go through these, just working our way down. C2, a hangman's fracture. This is a fracture through the pars. This is a fracture right here. There's different mechanisms for how it happens. It gets its name from the judicial hangings of yore, but we still see them quite frequently. A hangman's fracture like this, there's different ways of managing it. The ones that are very mild where they're non-displaced, there's no disc disruption that can be managed in a collar. The ones with severe disc disruption or just slipping, one spondylolisthesis where one bone is slipped on the other are often managed surgically. This is a good example of where the bone fracture doesn't matter as much as the associated disc and ligament disruption. So if you look at a fracture like type one and there's no disc and ligament disruption, this thing will heal fine. If you look at the ones where there's a significant amount of disc disruption or ligament disruption, then it really is more unstable and generally requires surgery for it. So getting the MRI scan of these and really paying attention to the soft tissue signal, the signal within the disc, this is really important in making a decision about which of these are stable or not stable. Here's an important and very common thing that you guys will all encounter in practice, something called a central cord syndrome. A central cord syndrome is an incomplete spinal cord injury. You can think of it as like squeezing or pinching the spinal cord, not necessarily associated with the fracture. A lot of times it's seen more commonly in elderly because those are the people that have narrower spinal canals, just from arthritis and stuff like that. Those have good range of motion. It may be a low energy injury. So just a ground level fall. Often it'll be a hyperextension. So they lean backwards. And when they lean back, they kind of pinch off the spinal cord. So it's usually hyperextension in the setting of stenosis and people will develop weakness, numbness, tingling into their arms and legs, but typically affects the arms more than the legs. And that's just because of the way the spinal cord is bruised kind of the center of it. That's why it's called a central cord syndrome. This is a kind of a picture of what might happen to somebody with severe stenosis, might have a minor injury, just a trip and a fall, banging their head against a cabinet or bump their chin against something and have a pretty severe spinal cord injury from it. Again, there may not be a fracture associated with them. So in terms of management, the controversies around it are really like, do you operate right away or do you operate later? And I'll try to distill this down. It's kind of in here with the text if you guys want to read it, but in terms of the genesis of it. But the optimal timing is controversial. We tend to be people that say like, look, as soon as somebody comes into an incomplete spinal cord injury, we take them to surgery, we decompress the spinal cord, give them a chance to get better. And it seems rational to do that. So in the question that I asked, the three days seems like pretty soon after me trying to one day, two days, three days, try to stabilize them. Other people believe like most of the time, central cord syndromes, they kind of get better. Like you get an injury and then people slowly are like, now I can feel my hands, now I can feel my legs. They kind of get better and better. So the rationale for waiting is like, let's let people get better. Why put them through surgery where they could have a hypotensive episode or something else negative that could happen or they develop a pneumonia afterwards or something else that can really affect their spinal cord injury, let them recover and do it in a delayed fashion. The normal course of central cord syndrome is people get better and then they plateau and then they have a late decline or disimprovement. That was kind of what's traditionally believed. So one model for treating them is to treat them upfront, generally within five days. One model is to treat them kind of delayed after six weeks, but before they start declining. What's clear is if you operate on people in the interval, at that three week mark in that question that I asked, there's a higher rate of having medical issues or problems in that window and having a worse outcome in the long run. So generally we don't operate in that window between five days and six weeks. We usually operate early or sometimes we'll get these consoles on a fracture that happened or a fall that happened two weeks ago and we wait and let them cool off and then practice the second one. Now, every place will have its own style, but that's the rationale around timing for this. The general treatment for it is posterior cervical, not always, but posterior cervical to take the pressure off the spinal cord. I think you guys kind of know what this is, but these are just pictures to kind of show it. So a burst fracture in the spine is something that here you can see the cervical spine, the bone itself fractures, presses on the spinal cord. There's fairly significant risk of spinal cord injury. And the treatment for that mostly ends up being surgery from the front, where you open up from the front, take out the broken bone like this and put in a little allograft or some other type of a spacer or something to kind of split the difference in a plate on the front. And that's a pretty good way of treating it, achieves the decompression and restores alignment, et cetera. Facet dislocation is a little trickier. When these facets, if they're broken, it may not be a big deal, but a lot of times these will be locked in place. And so you have to get them unlocked. So kind of back to restore normal alignment. Restoring alignment is not only important for alignment, but it's also important because it opens up the space around the spinal canal. To mention like unilateral facet dislocations, a lot of times we'll have more ligament preservation. So there's sometimes harder to reduce a one-sided facet dislocation. For somebody to dislocate both facets, usually there's a lot of ligament disruption. Interestingly, those patients, less common, they will have, it's very common to have a fracture, a spinal cord injury with a unilateral facet dislocation because there's a lot of bony preservation. Bilateral, interestingly, usually the posterior arch is so disrupted that a lot of times you'll see the lamina will actually float back and you'll see bilateral facet dislocations without a spinal cord injury or the less severe ones. So actually unilateral is more often associated with the severe spinal cord injury. This is just what it looks like. In terms of closed reduction, it's something to kind of talk about. There's not a very, we don't use it that often, mostly because we tend to get people to surgery pretty quickly. Back in the day, this was important. When I was in training, it was important to know how to put tongs on. It was a real to-do. You had to get like a fluoro in the room and a traction table and like get all this stuff done. Honestly, you can take these guys to surgery and be done with it in an hour, or you can spend four hours trying to reduce them and then take them to surgery. So we don't, I'm not gonna belabor much about that. In terms of thoracolumbar injuries, there's really a three column model for the spine, the anterior, middle, and posterior column. And the, this is a bit outdated, but valuable in thinking about how many columns, what's considered stable. An old school way of looking at this was if only one column was injured, it was stable. If three were injured, it was not. Something in between was variable. But so it's kind of valuable to kind of think roughly what type of fracture there are. Compression fractures are very common. You'll see them. It's generally managed in a brace. Sometimes people can get cement augmentation for them. It's a common fracture to have, but bracing is the typical mainstay treatment. The other thing to take away from it, when you see a person with osteoporosis, DEXA scan. That's probably the most important thing is to address, identify and address their osteoporosis. And then finally, thoracolumbar burst fractures. So these are fractures that are, you know, protean, but this is designed to show here. They really concentrate at a junction between the thoracic and the lumbar spine, where it's like a very stiff barrel flexing forward on the lumbar spine and something cracks. You'll see it's most commonly at L1, T12 and L2, you know, follow right afterwards. The management options for it, if it's stable, so there's not a lot of ligament disruption neurologically intact person, you can put these people in a brace and that's commonly done. We do that a lot. And the ones that are not, so if there's a neurological injury or significant ligament disruption, then surgical treatment is an option. And there's two approaches for it. The first to talk about is an approach from the front, where you can kind of come in. The value here is you come in from the front, which is to say the side and take out this bone from the side and replace it with a little spacer. So it kind of looks like this. You're working from the side, you take out the broken bone, you put a little spacer and a plate on, and here's a picture of that. The other option for doing it is to do it from the back. And usually if you do it from the back, you have to go two levels up, two levels down. So good fixation above, good fixation below, it's so-called cantilever construct. And you can get back pretty good alignment as well. It's less morbid, but you usually have to sacrifice more levels when you do that. And then here's an MIS picture kind of showing the same thing. So I'm almost out of time. I will say you can do both front and back when you have burst fractures. And here's an example of that. And that would be to really address the fact that you want to get the body off the nerves themselves, but not sacrifice a bunch of levels by going in from the back alone. So in conclusion, spine trauma is common. It's increasing in incidence. It affects the younger population. Certainly our performance in those situations is really relevant. Prompt immobilization and evaluation are essential. Understanding the fracture morphology and neurological status really define what the management course is. But this is designed to really give you some familiarity with the different things we encounter. And then hospital care makes a big difference in minimizing secondary injury. And in a young population with a big economic impact, it makes this a very important problem to understand. Thank you very much. Thank you, Dr. Prasad. It was an excellent lecture. We have multiple questions that we're not able to answer right now, but we will answer it in the Q&A that follows this. So if you did have a question, please hang on and we will address it at that point. Thanks everyone.

spinal cord injury

evaluation

management

complete spinal cord injury

incomplete spinal cord injury

intact spinal cord injury

pre-hospital evaluation

non-operative treatment