After initial care of the patient with spinal injury, decision is made about the definitive care. A definitive care aims at making the injured spine stable and removing any decompression on the spinal cord.
Because not all patients would have neural injury and not all patients would have instability of the spine, the definitive treatment has a spectrum from immobilization with a collar to surgery. There are indications for each method and one treatment cannot treat all kind of injuries.
Following are the ways of treating a spinal injury
- Non operative Treatment
- Operative treatment
- Closed reduction with or without surgery (in cervical spine only)
Non Operative Treatment
Non operative treatment remains the standard of care for spinal injuries. Barring few types. Most of injuries can be treated with these methods.
Closed treatment options are
- Traction – In case of cervical spine injuries
- Bed rest with regular periodic turning to avoid bed sores.
- Halo apparatus, external orthosis, or cast.
Bed rest is advised for the initial few weeks and is followed by bracing. This option can be used in unstable injuries too. External orthosis is chosen as per level of the injury.
Bracing is continued for 8–12 weeks in cervical injuries and 12–24 weeks in thoracolumbar injuries. This is the time taken for the frcture to heal sufficiently to bear the load.
Prolonged bed rest as definitive treatment may be advised in rare cases of patients unwilling to undergo bracing or surgery or are unsuitable for that treatment because of severe preexisting deformity, morbid obesity, or medical problems etc.
In some patients, non operative treatment of may lead to chronic pain at a later date.
Operative Treatment
Surgical stabilization of the spinal column aims at
- Prevention of further mechanical injury
- Decompress spinal cord by removing the structures causing compression e.g. bone fragments pressing on the spinal cord
Following patients should be considered for surgery
- Skeletal instability with a neurologic deficit.
- Unstable ligamentous injury in adult patient where non operative treatment does not restore sufficient strength for stability
- Patients with multiple injuries
- Multiply injured patients
The surgery of injured spine varies as per level of the injury but the priniple followed are
- Decompression
- Fixation of the injured segment with implant
- Fusion of the segment with bone graft
The purpose of the implant is to hold the segment in the position till the time fusion occurs. If not fused, implant would fail some day and spine would again become unstable.
There are various gadgets available for spine surgery and each has its own advantages and disadvantages.
Closed Reduction
This method is used in cervical spine dislocations. The principle behind this is to use heavy weights to distract the injured area so that a slow maneuver can be performed to reduce the spine. It is quite safe method. Neurologic deterioration during reduction is a risk but is quite rare if done meticulously.
This needs insertion of Crutchfield tongs or Gardner-Wells tongs.
- In alert cooperative patients, imaging is not necessary prior to reduction
- An unconscious patient should be undergo an MRI scan before reduction.
- Injuries such as craniocervical dissociation or a cervical injury that shows distraction should not be put on traction.
Benefits of closed reduction
- Decreases the need for complicated surgical procedures
- Improves stability, prevent neurologic deterioration or can improve neurologic status
- Reduction within the first few hours of injury may lead to dramatic improvement in neurologic status.
There is no effective closed reduction technique for thoracolumbar spine.
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