Spine Trauma

Spine TraumaDr. Agus Guntoro SpBSDefinition Any injury that has occurred to any of the following structures:Bony elementsSoft tissuesNeurological structures

Anatomy

The SpineComposed of 33 vertebrae 7 cervical 12 thoracic 5 lumbar 5 sacral + 4 coccyx (fused)Act to support the trunk and transfer muscular loadAnatomy

Anatomy

Facet Joints

Ligaments

Intervertebral Disc

ETIOLOGY OF SPINAL CORD INJURY

TRAUMATIC :50% motor vechicle accidents20-30% Falls12-21% gun shots6-7% sport related activities NONTRAUMATIC ; Intraspinal tumorsInfections & inflammatory diseasesIntraspinal abscessesIatrogenic complications of surgical or diagnostic procedures

General Principles of TraumaPrimary SurveyAirway (with C-spine protection)Breathing and ventilation Circulation (with hemorrhage control)Disability - neurologic statusExposure and environmentResuscitationOther studies and monitorsSecondary survey

Vertebral InjuriesInjuries to the spine must be excluded after trauma:55% involve the cervical spine 15% involve the thoracic spine 15% involve the thoracolumbar region 15% involve the lumbosacral region

TWO IMPORTANT FACTORS IN SPINAL TRAUMAInstability of the vertebral columnActual or potential neurological injury

SPINAL INSTABILITY

Definition: Loss of normal relationship between anatomic structures with a resulting alteration of natural function:Spine can no longer carry normal loadsPermanent deformity may occur resulting in severe painPotential for catastrophic neurological injuryInstability results from:Fracture of vertebral body, lamina, and/or pediclesDislocation of anatomic components caused by disruption of soft tissuesFracture and dislocation may occur together

Classification of Fractures

Major and MinorMajor = fracture of vertebral body, pedicles, laminaMinor = fracture of transverse, spinous, articular processes

Classification of Fractures

Stable and UnstableStableSpine can withstand physical loadsNo significant displacement or deformity to bone or soft tissueUnstable Spine may not be able to carry normal loadsMost likely have significant deformity and painPotential for catastrophic neurologic injury

Denis Classification Method

Based on 3-column theory of the spine:Anterior = ALL and anterior 2/3 of vertebral body/discMiddle = posterior 1/3 of vertebral body/disc and PLLPosterior = pedicles, lamina, facets, post. ligaments

NEUROLOGIC INJURY

Definition: trauma to spinal cord, cauda equina, nerve rootsCan result from bone, bone fragments, or disc material compressing on neuro. structuresAll structures innervated by the affected neuro. structure may lose all or partial functionScoring of Neurologic Injury

Frankel ScoreA = Complete loss of motor and sensory functionB = Only sensory function remainsC = Motor function is present but of no practical use (i.e., can move legs but not walk)D = Motor function impaired (i.e.can walk but not with normal gait)E = No neuro impairment notedGENERAL PRINCIPLES OF MANAGEMENT

ImobilisationStabilized medicallyMaintain spinal alignmentDecompressionSpinal stabilisationRehabilitation

IMMOBILISATIONFrom the scene of accident to emergency roomStabilise the neck in neutral position Prevent rotation !Lay supine on a firm and even surfaceTransfer of patient using the four-men lift or use a Robinsons orthopaedic stretcher

MEDICAL STABILISATIONEspecially in a tetraparetic or tetraplegicNormalised vital signsMaintain adequate circulation and tissue perfusionMonitor urine productionMonitor blood gas analysisNeurogenic shock ?

MEDICAL STABILISATIONInsert NGT gastric decompression and prevention of stress ulcerInsert urinary catheter to monitor fluid output and to decrease the hypotonic bladderMega dose of methylprednisolone (???) Neurogenic Shock

Loss of symphatetic tone on the peripheryIncrease blood vessel capacityVenous swelling on lower extremitiesHypotension and bradycardiaHypothermia

Neurogenic Shock Treatment

Adequate fluid ( do not overload )Trendelenburg positionAtropine 0.4 mgCardiopressors to increase peripheral vascular tone and cardiac output

SPINAL ALIGNMENTIn fractures Gardner tongs tractionIn dislocation Gardner tongs traction with increasing weight every 10-15 until reductionIf closed realignment procedures fail open reduction and stabilisationAnteriorly or posteriorly

DECOMPRESSION

Realignment means..decompression !!If closed measures fail..open decompression and reductionAnterior decompression or posterior decompression ?

SPINAL (SURGICAL) STABILISATION

REHABILITATION

Should be initiated upon admissionOptimalisation of neurologic functionsBladder trainingBowel trainingEtc