Fracture-dislocations of the spine are often immediately fatal, especially when involving the upper four vertebrae. Dislocations uncomplicated by fracture are more common here than in other portions of the spinal column (see 'Anatomy', page 465). The usual deformity is kyphotic, though the displacement may be lateral, posterior, rotary or even overriding. Unilateral luxations are more common in the neck than in other portions of the spine, their usual seat being in the occipito-atlantal or in the atlo-axial articulations. If death does not follow the injury within a few hours motor and sensory disturbances develop in the regions supplied by the injured spinal segments and below the site of the lesion. Injuries at, or above, the fourth spinal segment destroy or interfere with the nerve supply to the diaphragm, and the proximity of the important centers in the bulb, together with the close association between the pneumogastric and spinal-accessory nerves, renders fractures in this region especially dangerous. When death is not immediate pronounced variations are usually observed in the temperature, pulse and respiration. The temperature may rise to 105° or 106° or even higher, the pulse becoming rapid and arythmic. The more complete the loss of function in the phrenic, the more pronounced will be the action of the accessory muscles of respiration provided they are still capable of action. Fracture of the cervical region may involve the segments from which the nerves of the brachial are derived, and the muscles paralyzed in the upper extremity will vary according to the level of the lesion. When the lesion involves the upper portion of the brachial plexus the upper extremities will be held in a characteristic position with the elbows flexed, and the upper arm abducted and rotated outward. Injury to the lower portion of the plexus produces a different attitude, with the arms not far from the side and the hands resting on the chest in pronation. The reason for these differences in attitude is explained by the formation and distribution of the brachial plexus. In complete lesions of the cervical cord death almost invariably occurs within a few hours, if not at the time of the accident. If the patient survives the immediate effects of the injury the usual motor and sensory paralyses develop below the site of the injury, including loss of sphincteric control. If he lives a few weeks trophic disturbances make their appearances, the most important of which is the bed sore. Fracture-dislocations of the thoracic region are more constant in their type of deformity than are corresponding injuries in either the cervical or lumbar spines. Kyphosis with crushing of the body of the vertebra is the rule. Fractures of the upper thoracic region do not commonly influence motion or sensation of the upper extremities, though the usual symptoms develop below the lesion according to the severity of cord injury. Loss of sphincteric control with sensory and motor disturbances of the legs and lower trunk are present. Diminished or lost peristalsis sometimes results in severe tympanites and fecal impaction, through interference with the nerve supply of the intestines. Any or all of the abdominal viscera may show diminished function. The thoracic portion of the spinal cord extends from the level of the sixth cervical interspace to the ninth thoracic vertebra, and hence fractures of the spine below this level involve the lumbar enlargement or the Cauda equina rather than the dorsal segments. Injury to the lumbar enlargement, situated opposite the lower three thoracic and first lumbar vertebra, gives rise to flaccid paralysis of the lower extremities, varying in degree with the severity of the lesion. The centers controlling the bladder, bowel and genitalia are all situated in this portion of the cord, and hence disturbances in function occur in these parts when this portion of the cord is injured. Injuries below the first lumbar vertebra may damage the nerves forming the cauda equina; the motor and sensory losses will vary according to the nerves injured. The reflexes in the lower extremities will be lost if the nerves are crushed. Shock will be much less than that accompanying injury to the cord itself even when all the nerves are crushed.<Callout type="important" title="Important">Always ensure proper fixation of the spine to prevent further damage.</Callout> Diagnosis. — The diagnosis of fracture of the spine and its complications, is based on the symptoms previously described. The alignment of the spine should be determined by inspection, and the tips of the spinous processes carefully palpated. Isolated fractures of the spines produce only local pain, abnormal mobility, and sometimes crepitus; the symptoms of fracture of the spine as a whole are absent. It is, as a rule, an easy matter to determine the presence of fracture in the spinal column, although an accurate appreciation of the details of the fracture is often only had by means of the X-ray or at autopsy. Unless the most careful examination is made in fractures without deformity the condition may be overlooked and subsequent displacement may produce injury to the cord which could have been prevented if proper fixation apparatus had been employed.<Callout type="warning" title="Warning">Failure to properly immobilize a spinal fracture can lead to severe complications.</Callout> The important element in fracture of the spine is that of cord injury, the degree and position of which determine the treatment. Complete transverse lesions produce immediate, total, permanent and symmetrical loss of motion, sensation and reflexes below the lesion. Partial lesions are usually followed by irregular, incomplete and asymmetrical motor, sensory and reflex losses. The motor losses below the lesion are spastic, while the paralyses in the muscles supplied by the injured segments are flaccid. In complete lesions the motor losses, at and below the lesion, are all flaccid. In cord injuries, loss of motion in a single muscle, or group of muscles, never occurs. Such a condition means injury to one of the peripheral nerves rather than a spinal segment or nerve root. When a spinal nerve is crushed in one of the intervertebral foramina, the motor and sensory losses are confined to the distribution of that single nerve root.<Callout type="risk" title="Risk">Crushing injuries can lead to secondary traumatic hematomyelia.</Callout> The loss of reflexes, accompanying shock and unconsciousness, often prevents the surgeon from making an early diagnosis. The degenerative and inflammatory changes within the cord, following pressure, may begin within a few hours of the injury, and hence the value of an early diagnosis is apparent. The symptoms of bony pressure are prompt in onset, and usually not progressive, while pressure due to hemorrhage produces symptoms which increase in severity as the blood escapes into or about the cord. Pressure myelitis, however, gives rise to symptoms which are practically identical with those of hemorrhage, and in a given case it is not infrequently impossible to differentiate between the two.<Callout type="tip" title="Tip">Early diagnosis can prevent further injury.</Callout> It is also extremely difficult in some instances to differentiate between a partial lesion due to bony pressure and that due to hemorrhage. The difficulties of diagnoses in these cases are greatly increased by the manner in which shock and unconsciousness sometimes obscure the symptoms for a number of hours following the injury. Symptoms simulating complete lesions frequently change within the first twenty-four hours, being replaced by the symptom-complex of a partial injury.<Callout type="gear" title="Gear">Plaster casts or steel braces are effective methods to immobilize spinal fractures.</Callout> The X-ray, especially in stereoscopic form, is sometimes of the greatest service in determining the extent to which the lumen of the spinal canal has been encroached upon by bony displacement. The level of the cord lesion is determined by the level of the motor and sensory disturbances, particularly the level of the hyperesthetic zone and the area of flaccid paralysis.<Callout type="important" title="Important">Maintain patient's position unchanged until the plaster has set to properly splint the parts.</Callout> Treatment. — The treatment of fractures of the spine is directed, firstly, towards the fixation of the injured portion of the column, and secondly, to the alleviation of complications and their symptoms. With the exception of isolated fractures of the spinous or transverse processes fracture of the spinal column calls for a fixation in some form regardless of whether or not the cord has been injured.<Callout type="warning" title="Warning">Manipulations should be gradual, gentle, and guarded to avoid further injury.</Callout> Fixation is most satisfactorily accomplished by means of a plaster cast, modified according to the region of the injury. In the cervical spine it should be so applied as to include the head, neck and shoulders, leaving the arms free. In the dorsal region, it will be necessary to include the chest and upper abdomen, together with the neck if the fracture is high. When the lower dorsal or lumbar vertebra are fractured the cast should extend from below the armpits to the hips, including the crests of the ilia. In whatever region the cast is applied, the deformity should be previously corrected as perfectly as possible, and the patient's position maintained unchanged until the plaster has become sufficiently set to properly splint the parts.<Callout type="tip" title="Tip">Use a stomach pad for comfortable respiration during treatment.</Callout> Fractures of the cervical spine may be held in reduction by the hands of an assistant while the cast is being applied. In the dorsal and lumbar regions, correction of the deformity is much more difficult because of the weight and bulk of the parts handled. Reduction in these portions of the column may be accomplished in a number of ways, any of which is satisfactory if properly performed.<Callout type="important" title="Important">Avoid unnecessary manipulation to prevent further displacement.</Callout> If the patient is placed on two tables, face downward, and the tables so separated that the body sags downward between them, the deformity will not uncommonly be reduced without further manipulation. Gentle pressure over the prominent spines may be necessary in addition to secure proper relations of the fragments. Two or three assistants will be necessary to securely hold the patient at the shoulders and heels to prevent his slipping off the tables, and to maintain the proper degree of spinal curvature.<Callout type="gear" title="Gear">The Bradford-Lovett hammock frame is an excellent apparatus for applying casts.</Callout> In this position the surgeon may begin the application of the plaster bandages, the skin of the trunk having been previously protected by means of a snug, soft woven shirt. Another method consists in suspending the patient in a hammock, and so regulating the tension at which the hammock is hung that the proper spinal curvature is obtained, and the deformity corrected.<Callout type="important" title="Important">Ensure the cast remains exposed to air for 24 hours.</Callout> Immobilization of the spine may be accomplished in other ways besides the plaster cast, though probably not any more satisfactorily in the usual case. Steel braces, similar to those employed in the treatment of Pott's disease, may be used in fixing the spine.<Callout type="warning" title="Warning">Water beds are less effective than casts or braces for immobilization.</Callout> The water bed has been much used in the treatment of these cases, though the fixation of recumbency alone is by no means as efficient as that produced by the cast or brace. In the early treatment of fracture of the spine, extension and counter-extension may be employed by means of Buck's apparatus applied to both legs with the foot of the bed raised.<Callout type="important" title="Important">Maintain proper dorsal curvature during treatment.</Callout> Sand bags about the body serve to steady the parts, and a small, hard pillow under the small of the back will maintain the proper dorsal curvature. The Bradford frame may be used to advantage when simple recumbency is the method of fixation.<Callout type="warning" title="Warning">Complications such as hemorrhage can worsen symptoms.</Callout> If the fracture is complicated by cord or nerve injury, the indications to be met in the treatment are much more complex. In addition to fixation of the spine, the relief of symptoms resulting from the complication is demanded as far as may be possible. This may, or may not, require operation.<Callout type="important" title="Important">Operate only when necessary to avoid complications.</Callout> When an absolute diagnosis of complete crushing to the cord can be made, operation is contraindicated, since it can do no good. In partial lesions we should open the spinal canal at the seat of injury for the removal of such pressure as
Key Takeaways
- Proper immobilization is crucial to prevent further spinal damage.
- Early diagnosis can help manage complications effectively.
- Different regions of the spine have distinct symptoms and treatments.
Practical Tips
- Always use a proper cast or brace for spinal fractures to ensure stability.
- Maintain patient's position carefully during treatment to avoid additional injury.
- Regularly monitor patients for signs of complications such as bed sores.
Warnings & Risks
- Failure to properly immobilize can lead to severe spinal injuries and complications.
- Manipulations should be gentle to prevent further displacement or damage.
- Complications like hemorrhage can worsen symptoms if not managed promptly.
Modern Application
While the techniques described in this chapter are rooted in historical practices, the principles of proper immobilization and early diagnosis remain crucial for modern survival scenarios. Understanding these concepts can help in managing spinal injuries effectively, whether during natural disasters or other emergencies.
Frequently Asked Questions
Q: What is the most common type of deformity seen with cervical spine fractures?
The usual deformity is kyphotic, though it may also be lateral, posterior, rotary, or even overriding. Unilateral luxations are more common in the neck than in other portions of the spine.
Q: How does a complete transverse lesion affect motor and sensory functions?
Complete transverse lesions produce immediate, total, permanent, and symmetrical loss of motion, sensation, and reflexes below the lesion. The motor losses are all flaccid, while the paralyses in the muscles supplied by the injured segments are also flaccid.
Q: What complications can arise from fractures involving the cervical cord?
Fractures of the cervical cord may involve the segments from which the nerves of the brachial plexus are derived, leading to paralysis in the upper extremities. The phrenic nerve is also at risk, potentially causing respiratory issues.