kuliah mahasiswa spinal cord injury terbaru
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TRAUMA MEDULASPINALIS
Dr. Rendra leonas SpOTORTHOPAEDIC SPINE SURGEON
DEPARTMENT OF SURGERY
MOH. HOESIN PALEMBANG
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Introduction
Most common
age and high speed level
traffic accident >>80% spinal inj not assoc SI
more important preliminary care
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At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.
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Introduction
Trauma spine can cause damaged :
Hard tissue : bone
Soft tissue : ligamentdiscus
spinal cord
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Introduction
Careful Physical Examination is potentially
the most valuable service a physician can
provide to the patient. ( OKU Spine : 2004 )
Complete exam :
Correct diagnosis
Magnitude of the problemDetermine appropriate Treatment
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Anatomy and Physiology
33 bones comprise the spine Function
Skeletal support structure
Major portion of axial skeleton
Protective container for
spinal cord
Vertebral Body Major weight-bearing
component
Anterior to other
vertebrae components
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Anatomy and Physiology
Characteristic of the
Vertebrae
Cervical
C-1 & C-2 novertebral body
Support head
Allow for turning of
head Vertebral body size
increase inferiorly theybecome
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Anatomy and Physiology
Characteristic of
theVertebrae
Lumbarspine has
strongest andlargest
weight bearing of
the body
Sacral & Coccyx
vertebrae are fused
No vertebral body
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Anatomy and Physiology
Components ofVertebrae
Spinal Canal Opening in the
vertebrae that thespinal cord passesthrough
Pedicles
Thick, bony structuresthat connect thevertebral body to thespinous andtransverse processes
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Anatomy and Physiology
Components of Vertebrae Laminae
Posterior bones of vertebrae that make up foramen
Spinous Process Posterior prominence on vertebrae
Intervertebral Disks Cartilagenous pad between vertebrae
Serves as shock absorber
Transverse Process Bilateral projections from vertebrae
Muscle attachment and articulation location with ribs
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Intervertebral Disc
nucleus
pulposus
annulus
fibrosus
hyaline cartilage
end plates
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Facet Joints
Act to limit shear and torsion
motions between vertebrae
Orientation of facet changes
along length of spine
Cervical : couple lateral
bending and torsional
motion
Thoracic : coronal plane
orientation of joint surfaces
Lumbar : sagital planeorientation of joint surfaces
Facets carry 10-20% of
compressive load in upright
standing, >50% of anterior
shear load in forward fexion
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Anatomy and Physiology
SPINAL NERVES 31 pairs of spinal nerves :
8 cervical
12 thoracic
5 lumbar
5 saccral
1 coccygeal
Each has both motor and sensory fibers Motor fibers = anterior or ventral root
Sensory fibers = posterior or dorsal root
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OVERVIEW
LOOK
inspection
FEEL palpation
MOVE
active & passive
movements
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Look :
bruise
hematom
wound : gun shoot wound
stab wound
Deformity
EXAMINATION : STANDING
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EXAMINATION :STANDING
Feel : Tenderness: may be bony, intervertebral or
paravertebral
Bony prominence or stepsspinous processes using C7 &/or L4-5
as landmarks
facet joints approx. 2cm lateral to spinous processes
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Feel :
assess alignment, mobility &
tenderness of: transverse processes of vertebrae
lateral to spinous processes
EXAMINATION : STANDING
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EXAMINATION :STANDING
Feel : Tenderness: may be bony, intervertebral or
paravertebral
Bony prominence or stepsspinous processes using C7 &/or L4-5
as landmarks
facet joints approx. 2cm lateral to spinous processes
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Feel :
assess alignment, mobility &
tenderness of: transverse processes of vertebrae
lateral to spinous processes
EXAMINATION : STANDING
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Signs of nerve root
compression
Standard full neurological examination of
both lower limbs :
tone, power (MRC grading) sensation (light touch, pinprick &
proprioceptive if indicated)
reflexes (physiologic and patologic)
an anatomical distribution [dermatome(s) or
myotome(s)]
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Neurological Examination
Objectives :
Determine if defect is present
Localize the level of the deficit
Include :
Sensory
Motor
Reflex
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Neurological Examination
Sensory examination Explain, eyes closed
Examine : touch, 2 point discrimination,
proprioceptive.
Sensory dermatomes, compare each
opposite
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Sensory Dermatome
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Muscle Power Grading
0 - complete paralysis
1 - flicker of contraction possible
2 - movement is possible when gravity is
excluded
3 - movement is possible against gravity
4 - movement is possible against gravity + some
resistance 5 - normal power
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Neurological Examination
Motor examination Muscle grading
Compare each side
Cervical :
Scapular C4Deltoid & Biceps C5Wrist extension & supination C6Wrist flexion & Pronation C7
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Neurological Examination
Motor
examination
Lumbo-sacralHip flexorHip extensor
L 1,2,3
S1Knee flexor
Knee extensor
L 4,5, S1,2L 2,3,4
Ankle flexorAnkle extensor S1L5
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ReflexesBiceps Triceps
Brachioradialis Hoffman
PROVOCATIVE TESTS
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PROVOCATIVE TESTSTEST COMMENTS
SLR : sitting & supine Must produce radicular symptom in the distribution of theprovoked root, for sciatic nerve , that means pain distal to knee
Lasgue's sign SLR radiculopathy aggravated by ankle dorsoflexion
Contralateral SLR Well-leg SLR puts tension on involved root from opposite direction
Kernig's test The neck is flexed chin to chest. The hip is flexed to 90, and thenthe leg is the extended similar to SLR; radiculopathy is reproduced
Bowstring sign SLR radiculopathy aggravated by applying pressure over poplitealfossa.
Femoral stretch test Prone patient; examiner stretch femoral nerve roots to test L2-L4irritation
Nafziger's test Compression of neck vein for 10 s with patient lying supine ;coughing then reproduces radiculopathy
Milgram's test
Patient raises both legs off the examining table and hold thisposition for 30 s; radiculopathy maybe reproduced
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Denis 3 Column Theory
Denis, F.: The Three-Column Spine and its Significance in theClassification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)
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Basic Types of Spine Fractures
1. Compression fracture
2. Burst fracture DenisClassification
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Basic Types of Spine Fractures
3. Seat-belt injury (Flexion-distraction
injury)
Bony Chance fracture Soft tissue Chance injury
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Basic Types of Spine Fractures
4. Fracture-dislocation
Flexion-rotation Flexion-distraction
Anterior posterior shear
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Classification spine fracture
Location :
1. Jefferson fracture
2. Dens fracture3. Hangmans fracture
4. Clay shovelers fracture
5. SCIWORA
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Compression fracture
Failure of the anterior column
Mechanism anterior or lateral flexion
Normally Stable or unstable fracture Rarely involved neurologic comprimise
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Criteria unstable
Loss of 50% of vert body height
Angulation of thoracolumbar junct > 20deg
Mutiple adjacent column of spine
Failure of 2/3 of column of spine
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Chance fracture
Anterior column falls in tension (along w/
the middle and posterior columns)
Three columns rupture in distraction
(tension)
Seldom assc w/ neurologic comprimise
unless
Unstable
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Burst fracture
Compressive failure of vert body both
anteriorly & posteriorly , w/ failure of both
anterior & middle columns
Axial loading applied to intravertebral disc
results in increased nuclear pressure and
hoop stresses in the annulus
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Burst frx location
Cervical burst fix
Lumbar burst fix Thoracic burst fix
Thoracolumbar burst fix
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Classification :
Stable frx
- neurologically intact- poterior arch remains intact : pedicl
widening implies post arch disruption
- less than 50% anterior body height- compression fracture
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Unstable frx
- neurologic defisit
- loss of 50% vertebral body height- fracture dislocation
- thoracolumbar burst frx
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Jefferson Fracture
Pediatric frx
- frx proceeds thru open synchondroses,
and may occur w/ minimal trauma/- posterior synchondroses fuses at age 4
- anterior synchondroses fuses at age 7
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Mechanism
- original description in 1920 noted role of
axial compression- may also be caused by hyperextension,
causing a posterior arch fracture
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Associated injuries
- approx 1/3 of these fractures are
associated with a axis fracture- approx 50% chance that some other
C-spine injury is present
- low rate of neurologic deficits is due tolarge breadth of C1 canal
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Radiographs
Odontoid view
Lateral view
Flexion and extension views
CT scan
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Dens Fracture
Odontoid fractures are the most common
upper cervical spine fratures
Remember rule of thirds cervical cord
occupies a 1/3 of canal, dens occupies a
1/3 and the remaining 1/3 is empty
Mechanism
Flexion loading
Extension loading
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Classification
Type I
Type 2 Dens frx
Type 3
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Associated Injury
Atlas frx
Transverse ligament rupture
Pharangeal injury
H f /T ti
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Hangmans frx/Traumatic
Spondylolisthesis of the Axis
Fix of pars interarticularis of C2 & disruption of C2-C3
junction
Type of traumatic spondylolisthesisHangmans frx
Term Hangmans fracture is not accurate for the majority
of cases, because mechanism of injury for clinically
encountered frx often lacks large traction force present in
judicial hangings
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In cases in which there is neurologic
injury, there will usually be significant
horizontal translation w/ accompanying
damage to the posterior longitudinalligament w/ or w/o damage of the C2 C3
interspace
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Mechanism of injury in adults
Judical lesion : hyperextension and distraction
Hyperextension w/ vertical compression ofposterior column, & translation of C2 and C3
Forceful extension of already extended neck
is most commonly described mech of injury,
but other causes include flexion of flexed neck
& compression of an extended neck
A blow on the forehead forcing the neck into
extension is a classic mechanism of injuryproducing fractures thru the pedicles of C2
known as traumatic spondyloslishthesis of C2
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SCIWORA Syndrome
Occurs may often in pediatric population
Accounts for up to 2/3 of severe cervical
injuries in children < 8 years of age
Inherent elasticity in pediatric cervical
spine can allow severe spinal cord injury
to occur in absence of x-ray findings
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Radiographs
Diagnosis of exclusion
MRI may give a more anatomic diagnosis by
showing hemorrage or edema of the spinalcord
Pseudosubluxation : anterior displacement
may be up to 4 mm
Clasification spinal cord
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Clasification spinal cord
injury Complete
Incomplete
Anterior cord syndrome
Central cord syndrome
Brown sequad
Cauda equina
A t
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Anatomy
crossection spinal cordAscending Tract
Tracts of Goll and Burdach
(fasc gracilis and cuneatus
Proprioception,vibration,dis
crimination
uncrosssed
Dorsal and ventral
spinocerebellar tract
Proprioception, light touch uncrossed
Lateral spinothalamic tract Pain, temperature crossed
Spinal olivary tract Tendon and muscle
proprioception
crossed
Ventral spinothalamic tract Deep tactile and pressure
sensation
crossed
Descending Tract
Lateral corticospinal tract
(pyramidal)
Motor control uncrossed
Rubrospinal tract Cerebellar reflexes crossed
Lateral reticulospinal tract Inhibits locomotor conytrol crossed
Reticulospinal tract Facilittes locomotor control uncrossed
Vestibulospinal tract Postural control Uncrossed
Tectospinal tract Eye and ear reflleces crossed
Complete / incomplete Spinal
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Complete / incomplete Spinal
Cord Lession
Complete cord injury : there is complete loss of
sensation and muscle function in the body below
the level of the injury
An injury to the upper portion of the spinal cord
in the neck can cause quadriplegia-paralysis of
both arms and both legs. If the injury to thespinal cord occurs lower in the back it can cause
paraplegia-paralysis of both legs only.
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Incomplete lesion : there is some
remaining function below the level of theinjury. In most cases both sides of the
body are affected equally.
Present when there is any distal sparing of
motor or sensory function along with
sparing of perirectal sensation
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Diff dx of incomplete lesions
Central cord syndrome Brown sequard syndrome
Anterior cord syndrome
Posterior cord syndrome Isolated nerve root injury
Cauda equina syndrome (w/ or w/o root
escape)
Conus medullaris injury
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Anterior Cord Syndrome
Damage is primarily in theanterior 2/3 of cord and is
related to vascular insuffiency
There is sparing the posterior
columns
Syndrome is manisfested by
complete motor paralysis
(corticospinal func) and
sensory anesthesi
(spinothalamic func)
Patient demonstrates greater
motor loss in the legs than
arms
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Prognosis
anterior cord syndrome has the worst prognosisof all cord syndromes
prognosis is good if recovery is evident &
progressive during first 24 hours
after 24 hrs, if no signs of sacral sensibility to
pinprick or temp are present,
prognosis for further functional recovery are
poor; only 10 to 15% of patients demonstratefunctional recovery;
Central Cord Syndrome
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Central Cord Syndrome
most common incomplete cord lesion
frequently associated w/ extension injury
to osteoarthritic spine (cervical
spondylosis) in middle aged person whosustains hyperextension injury
cord is injured in central gray matter, &
results in proportionally greater loss ofmotor function to upper extremities than
lower extremities w/ variable sensory
sparing;
http://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesionhttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injurieshttp://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injurieshttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesion -
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Anatomy:
fibers responsible for lower extremitymotor and sensory functions are located in
the most peripheral part of the cord
whereas fibers controlling the upperextremity and voluntary bowel and bladder
function are more centrally located
sacral tracts are positioned on theperiphery of the cord & are usually spared
from injury;
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Mechanism of Injury:
hyperextension injury
central cord injury and hemorrhage occur
with compression of adjacent white-matter
tracts more peripheral positioning of lower
extremity axons within the spinal cord
tracts accounts for the injury pattern
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damage to central portion of corticospinal
and spinothalamic long tracts in white
matter produces upper motor neuron
spastic paralysis of trunk and lowerextremity
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Examination
central cord syndrome is remarkable formore cord involvement in the upper
extremities than in the lower extremities
manifests w/ loss of distal upper extremitypain & temperature sensation and
strength, w/ relative preservation of lower
extremity strength & sensation
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upper extremities:
mixed upper and lower-motor-neuron lesion, w/
partial flaccid paralysis of upper extremities
(indicative of involvement of lower motor neurons)
prognosis is variable w/ poor hand function
lower extremities:
spastic paralysis of lower extremities (indicative of
involvement of upper motor neurons) bladder and bowel function may also be lossed;
Brown Sequard Syndrome
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Brown Sequard Syndrome
type ofincomplete cord syndrome
injury to either side of spinal cord
produces ipsilateral muscle paralysis
(from corticospinal tract injury) andcontralateral hypersthesia to pain and
temperature (from spinothalamic injury)
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syndrome results from hemitransection of
spinal cord w/ unilateral damage to the
spinothalamic & corticospinal tracts and
resultant loss of ipsilateral motor & dorsalcolumn function & of contralateral pain and
temperature sensation
often due to penetrating trauma orunilateral facet fracture ordislocation;
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Prognosis:
this syndrome has a good prognosis for
recovery
more than 90% of pts regain bladder &
bowel control & ability to walk
most patients will regain some strength in
lower extremities and most will regain
functional walking ability;;
Cauda Equina Syndrome
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Cauda Equina Syndrome
urinary retention is the most consistent
finding
in spinal cord injuries, the caudal equina
may sustain considerable initial trauma
in any potential cauda equina syndrome it
is important to examine for saddle
anesthesia, rectal tone, bulbocaverosusreflex, and sacral sparing;
http://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/sacral_sparinghttp://www.wheelessonline.com/ortho/sacral_sparinghttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflex -
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Initial Evaluation
ABC
Airway, Breathing, Circulation and C-spine
Back board with C-spine immobilization
C-spine lateral x-ray
Management of neurogenic shock
Vascular hypotension with bradycardia
Volume replacement, vasopressor
Avoid pulmonary edema from fluid overload
Associated life-threatening injuries
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Spinal Shock
Usually < 24 hrs
Check for BulboCavernosus reflex!!!
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Image Study
Plain x-ray
Vertebral height
Focal kyphosis
Level and type of injuryAbove T9 spinal cord injury
T10 to L1 spinal cord or rootinjury
Below L2 root injury
Computed tomography
Canal compromise
Myelography, MRI
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Neurologic Deficits1
Complete vs. Incomplete Injury?
Sacral sparing Incomplete injury
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Frankel Classification
A. Absent motor and sensory function
B. Sensation present, motor function
absent
C.Sensation present, motor function
active but not useful (grade 2-3/5)
D.Sensation present, motor function
active and useful (grade 4/5)E. Normal motor and sensory function
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ASIA Classification
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Neurologic Deficits
High dose methylprednisolone
30 mg/kg bolus IV injection in 1st hour
5.4 mg/kg/hr continuous IV infusion since 2
nd
hour
Given in 3 hours after injury: maintain 24-hr
therapy
Given beyond 3 hours after injury: maintain 48-hrtherapy
Given beyond 8 hours after injury: no benefit!!!
S
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Surgical Treatment
Indications:
Neurological deficits (+)
Neurological deficits (-)
Fracture-dislocations
Burst fractures
Anterior vertebral height collapse >50%
Focal kyphosis > 30
Canal compromise > 50%
Sagittal index (SI) > 25
S i l T
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Surgical Treatment
Goals:
To create an optimal environment for
neural recovery
To ensure stabilization and early
mobilization
To minimize further neurological
compromise from late deformity
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