management of spinal injury - ron 2
DESCRIPTION
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LARONA HYDRAVIANTO
Department of Surgery RSUD SIDOARJO
MANAGEMENT OF SPINAL INJURY
IntroductionSPINAL CORD INJURY (SCI)
18 - 35 years Global :25
0.000 - 500.000 people suffer every year
40- 80 cases per million population
Male : female= 4 : 1
Spinal Column Function
Anatomy
• Vertebral column- 7 cervical- 12 thoracic- 5 lumbar- 5 sacral - 4 coccygeal
Spinal cord 31pairs of
spinal nerves are attached to the spinal cord :
- 8 cervical - 12 thoracic - 5 lumbar - 5 sacral - 1 coccygeal
The dorsal roots of spinal nerves contain afferent (or sensory) fibers
The ventral roots of spinal nerves contain efferent (or motor) fibers
Goal of Spine Trauma Care
• Obtain healed & stable spine
Principles of Diagnosis and Management
Spinal Immobilization
Spinal Immobilization
Spinal Immobilization
Contraindications to neutral position
LESS MOVEMENT IS BEST
Helmet RemovalTechnique• 2 Rescuers• Remove face mask and chin strap• Immobilize head
Slide one hand under back of neck and headOther hand supports anterior neck and jaw
• Remove helmetGently rock head to clear occiput
• All actions should be slow and deliberate
Diagnosis
Radiographic Imaging
NEXUS• NEXUS Criteria :
1. Absence of tenderness in the posterior midline2. Absence of a neurological deficit3. Normal level of alertness (GCS score = 15)4. No evidence of intoxication (drugs or alcohol)5. No distracting injury/pain
fulfilled all 5 of criteria low risk for C-spine injury No need C-spine X-ray
any of the 5 criteria radiographic imaging was indicated (AP, lateral and open mouth views)
Radiolographic Evaluation
X-ray Guidelines (cervical) AABBCDS
• Adequacy, Alignment• Bone abnormality, Base of skull• Cartilage• Disc space• Soft tissue
Adequacy
Alignment• The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities
• Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation
• A step-off of >3.5mm issignificant anywhere
Lateral Cervical Spine X-Ray
• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a
vertebral body unilateral facet dislocation
– > 50% bilateral facet dislocation
Bones
Disc
• Disc Spaces– Should be
uniform
• Assess spaces between the spinous processes
Soft tissue
• Nasopharyngeal space (C1)– 10 mm (adult)
• Retropharyngeal space (C2-C4)– 5-7 mm
• Retrotracheal space (C5-C7) – 14 mm (children)– 22 mm (adults)
AP C-spine Films• Spinous processes should
line up
• Disc space should be uniform
• Vertebral body height should be uniform. Check for oblique fractures
Open mouth view
• Adequacy: all of the : all of the dens and lateral dens and lateral borders of C1 & C2borders of C1 & C2
• Alignment: lateral : lateral masses of C1 and C2masses of C1 and C2
• Bone : Inspect dens for lucent fracture lines
CT Scan• Thin cut CT scan should be
used to evaluate abnormal, suspicious or poorly visualized areas on plain film
• The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%
• Unable to adequately assess on plain films
• Sagittal and/or coronal reconstructions can be helpful (particularly at Occipitocervical and C-T junction.)
MRI
Principle of treatment
• Spinal column alignment– deformity/subluxation/dislocation
reduction
• Spinal column stability– unstable stabilization
• Neurological status– neurological deficit decompression
Spinal shock• Temporary loss of all or most spinal reflex
activity below level of injury• Lasts around 24 hours (max 48 hrs)• Ends when bulbocavernosus reflex and/or
anal wink returns • An injury cannot be considered complete
until resolution of spinal shock
• Autonomic function/ loss of sympathetic ( hypotension, bradycardia) neurogenic shock
Pharmacologic Pharmacologic TTreatment reatment of Spinal Cord of Spinal Cord IInjurynjuryNational Acute Spinal Cord injury Study
(NASCIS) II :• methylprednisolone (within 8 hours):
significantly better neurologic recovery • after 8 hours: worst outcome (relatively
high rate of complications) NASCIS III : improved recovery when tx extended to 48
hours (if drug therapy was started within 3 to 8 hours)
Pharmacologic Pharmacologic TTreatment reatment of Spinal Cord of Spinal Cord IInjurynjuryDosage :
– 30 mg/kg of IV methylprednisolone (for 1 hour)
– followed by 5.4 mg/kg (administered over the next 23 hours)
– if administered within 3 hours of injury– when is initiated 3 to 8 hours after injury
: maintained for 48 hours
Jefferson Fracture
• Burst fracture of C1 ring• Unstable fracture• Increased lateral ADI on
lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view
• Need CT scan
Burst Fracture
• Fracture of C3-C7 from axial loading
• Spinal cord injury is common from posterior displacement of fragments into the spinal canal
• Unstable
Optimal treatment of cervical burst fractures is anterior corpectomy, decompression, reconstruction, and plating
Clay Shoveler’s Fracture
• Flexion fracture of spinous process
• C7>C6>T1• Stable fracture
Flexion Teardrop Fracture
• Flexion injury causing a fracture of the anteroinferior portion of the vertebral body
• Unstable because usually associated with posterior ligamentous injury
- Surgical intervention is almost always indicated- Anterior neural decompression in the form of corpectomy, followed by reconstruction with strutgraft or cage as well as static anterior cervical plating and posterior-instrumented arthrodesis
Bilateral Facet Dislocation
• Flexion distraction injury• High incidence of spinal
cord injury• Extremely unstable
Hangman’s Fracture
• Extension injury• Bilateral fractures
of C2 pedicles (white arrow)• Anterior dislocation
of C2 vertebral body (red arrow)
• Unstable
Odontoid Fractures
• Generally unstable• Type 1 fracture through the
tip– Rare
• Type 2 fracture through the base– Most common
• Type 3 fracture through the base and body of axis– Best prognosis
Thoracic and Lumbar Fractures
Stability of The Spine
Instability may cause :1. Mechanical problem
Compression fracture that lead to kyphotic deformity.
2. Neurological disturbance Extraction of the bone fragment into spinal canal → regression of the neurological function.
Both can happen together
Denis Three Column Concept
Denis classification of thoracolumbar fractures
Surgical treatment is indicated for :
Compression fracture• Result from an axial loading
force acting on a flexed spine
• Usually stable• Can be treated nonsurgically• Bracing for 6 weeks with
subsequent physical therapy led to a better outcome than casting for 6 – 12 weeks
Burst fracture
• Burst fracture with more than 50% height loss, 30° of kyphosis, or a neurologic deficit riginally were identified as unstable and requiring surgical treatment
• PLC is important in determining the stability
• The goal of treatment of is to prevent the progression of deformity and neurologic injury
Burst fracture
• Hyperextension cast or thoracolumbosacral orthosis for 8 – 12 weeks
• Surgical option : - Posterior approach - Anterior approah - Combined anterior-posterior approach
Stable Burst fracture
Unstable Burst fracture
Flexion distraction (Chance fracture)
Translation-rotation injuries
• Highly unstable shear injury or fracture-dislocation
• Requiring surgical stabilization
Fracture-dislocation