c5 c6 dislocation

46
ORTHO CONFERENCE Ext pattraporn

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Page 1: C5 C6 dislocation

ORTHO CONFERENCEExt pattraporn

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HISTORY

Male 43 yr

cc: รถชน 3 hr PTA

PI : 3 hr PTA รถกระบะชนเสาไฟฟา้ มอีาการปวดต้นคอ มอีาการอ่อนแรงและชาท่ีแขนและ ขา ไมม่แีผลตามตัว สลบจำาเหตกุารณ์ไมไ่ด้ ไมม่อีาเจยีน ไมห่ายใจหอบเหนื่อย ไมป่วดท้อง

Past history : no underlying disease

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PHYSICAL EXAMINATION Primary survey

A : Can talk, tender at neck with limited ROM

B : Equal breath sound, CCT -ve, no subcutaneous emphysema

C : BP 96/60 mmHg, PR 66 bpm, no active bleeding

D : E4V5M6, pupil 3 mm RTLBE

E : no external wound

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PHYSICAL EXAMINATION

Vital sign : BP 96/60 mm Hg PR 90 bpm RR 20 /min Temp 37.2

GA : A Thai man , good consciousnessCVS : normal S1 , S2 , no murmur , cap refill < 2

secsLung : clear , equal both lung , no adventitious

soundAbd : soft , not tender , no guarding , no rebound

tenderness

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PHYSICAL EXAMINATION Can't flexion and extension neck tender posterior

Decrease sensation below C6

Bulbocarvernosus reflex -ve

Loose sphincter tone

RT LT

C5 II II

C6 II I

C7 II II

C8 0 0

T1 0 0

RT LT

L2 0 0

L3 0 0

L4 0 0

L5 0 0

S1 0 0

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INVESTIGATION

Film C-spine AP, Lateral

Swimming view

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SPINOUS PROCESS LINE

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Spinolaminar line

posterior vertebral body lineanterior vertebral body line

facet joints appear as stacked parallelograms

Prevertebral soft-tissue shadow Disc C2-C3 < 7mmDisc C6-C7 < 21 mm

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AP TRANSLATION

3.5 mm of translational deformity is suggestive of mechanical instability

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COBB ANGLE

>11 degrees suggestive of posterior ligamentous injury and potential instability

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CT SCAN• More sensitive for detecting fractures

• More consistently enables assessment of the occipitocervical and cervicothoracic junctions

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ALLEN & FERGUSON CLASSIFICATION

Distraction flexion II

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DISTRACTIVE FLEXION

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DIAGNOSIS

C5-C6 unilateral facet dislocation with complete cord injury

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INITIAL MANAGEMENT High dose Methyl-prednisolone Methyl prednisolone 30mg/kg then 5.4 mg/kg over the next 24 hours

On skull traction

MRI c-spine

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HIGH-DOSE METHYL PREDNISOLONE

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MRI• Superiority in visualizing the spinal cord, intervertebral

disc, and spinal ligaments

• Detecting

• traumatic disc herniations

• epidural hematoma

• spinal cord edema or compression

• posterior ligamentous disruption

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MRIIndication

• patients with neurological deficits

• patients with injuries in which the integrity of the posterior ligamentous complex is unclear and would directly influence the treatment plan

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TREATMENT

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SUBAXIAL CERVICAL SPINE INJURY CLASSIFICATION (SLIC)

<= 3 : nonoperative

>= 5 : operative

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TREATMENT

8 point

Operative treatment

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FACET DISLOCATIONNon-operative treatment

• Indication : unilateral facet dislocations without any signs of neurological injury

• Halo vest immobilization 3 month

• Flexion-extension views to confirm stability

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FACET DISLOCATIONOperative treatment

• Closed reduction using cranial tong or halo traction as early as possible in awake, conscious, and able to be serially examined patient

• Pre-reduction and post-reduction MRI

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FACET DISLOCATIONOperative treatment

• If there the spinal cord is being indented by a disc herniation, anterior surgery is preferred

• Anterior surgery followed by posterior stabilization for patients with highly unstable bilateral facet dislocations

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TREATMENT

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SPINAL CORD INJURY

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ANATOMY

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SPINAL CORD

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SPINAL CORD INJURY

Complete cord injury syndrome

Incomplete cord injury syndrome

Conus medullaris syndrome

Clauda equine syndrome

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COMPLETE CORD INJURY SYNDROME

After presence of bulbocavernosus reflex : no sensation or voluntary motor function is noted

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INCOMPLETE CORD INJURY SYNDROME

Some neurological function persist after return of bulbocavernosus reflex

Sacral sparing : imply continuity between cerebral cortex and lower sacral motor neuron.

Such as 1. Perianal sensation 2. Voluntary rectal motor function 3. Big toe flexor activity

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INCOMPLETE CORD INJURY SYNDROME

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INCOMPLETE CORD INJURY SYNDROME

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ANTERIOR CORD SYNDROMEBlood flow is reduced or interrupted in the artery that runs along the anterior portion of the spinal cord.

May be the result of bone fragments from traumatic injury to the vertebra, spinal disc herniations or flexion/compression injury.

Most poor prognosis : recovery rate 10%

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CENTRAL CORD SYNDROMEMost common type

Characterized by impairment in the arms and hands and, to a lesser extent, in the legs.

Spare sacral spine thalamus and corticospinal tracts

Recovery from distal to proximal [toe flexion > toe extension > ankle > knee > hip]

recovery rate 75%

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BROWN SEQUARD SYNDROMEHemisection of the spinal cord

Motor paralysis , loss of vibration and proprioception on the ipsilateral side as the lesion and deficits in pain and temperature sensation on the contralateral side of the lesion.

The most common cause of Brown-Séquard syndrome is penetrating trauma such as a gunshot wound or stab wound to the spinal cord.

Best prognosis : More than 90% of people regain bladder & bowel control and the ability to walk.

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POSTERIOR CORD SYNDROME

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SPINAL SHOCK

Immediate temporary loss of total power , sensation and reflexs below the level of injury

Loss of bulbocavernosus reflex

Usually recovery in 24-48 hrs