Cedera spinal

Cedera spinalFanny Indarto, dr. Sp.B

Trauma Manual, 3rd edition, 2008Spinal Cord Injury can occur without spinal column injury.Spinal column injuries can occur without spinal cord injury.

Spinal injury should be suspected in any patient with a head injury or severe facial or scalp lacerations. In any patient with recent trauma, complaints of neck pain or spinal pain should be considered indicative of a spinal injury until proved otherwise.Chambell, 2007The general assumption is that all patients have an unstable spine until proven otherwise.Patients with continued complaints of spine-related pain must be thoroughly evaluated and this evaluation must be repeated if the symptoms persist.

Trauma Manual, 2008Etiology

Trauma, Feliciano, 2008Spinal injury with neurologic defisit

Trauma, Feliciano, 2008

Bulbocavernal reflex

The absence of this reflex indicates spinal shock.The return of the bulbocavernosus reflex, generally within 24 hours of the initial injury, hallmarks the end of spinal shock. ( Handbook of Fracture, 2006)

Complete paralysisPreservation of vibration and touch sensations The prognosis for recovery is poor, with minimal chance of return of meaningful function.57Tetraparesis with arms, and in particular hands, weaker than legsVariable sensory loss that does not involve the face

Ipsilateral paralysisIpsilateral vibration and touch sensory lossContralateral pain and temperature loss

Tetraparesis is due to disruption of the lateral corticospinal tracts.Sensory loss is profound with the exception of pain and temperature.Spinal Cord Injury Syndromes

Orthopedic Surgery Essential, 2004

Spinal shockmostly occurs after significant cervical cord injury;characterised by a state of flaccid paralysis, hypotonia and areflexia (e.g. absent bulbocavernosus reflex)The sensory and motor symptoms usually resolve by 46 h, but autonomic symptoms can persist for days or weeksMost typical signs include bradycardia despite hypotension, flaccid paralysis and lack of painful sensation to the limbs affected; other

Handbook of Fracture, 2006PathophysiologyDisruption of the normal blood flow ischemia in the gray matter Although the white matter blood supply may not diminish, vasospasm can affect the ascending and descending tracts as arterioles pass through the gray matter to reach these tracts. Vasoconstriction can increase progressively over the first 24 hours the release of histamine, prostaglandins, serotonin, and neurotransmitters such as norepinephrine. Thrombosis of injured arteries contributes to ischemia, which is tolerated poorly by central nervous system tissue, initiating a cascade of ion derangement, inflammation, and apoptotic cell death.Injured cells release proinflammatory substances that attract neutrophils to the area within 24 to 48 hours; this causes an expansion of the damage in the rostral and the caudal directions. In 48 hours, macrophages and microglial cells migrate to the site and release reactive oxygen radicals that cause damage to the surrounding healthy tissue. Cellular membrane breakdown ionic imbalance and nucleolysis. As the energy supply necessary for restoration of membrane potential is depleted, K move out, and Na move in. Additionally, Ca is released activates enzymes in the proteolytic pathway -destroy the cytoskeletons of cell bodies and axons. All of these events lead to demyelination and necrotic cell death.ImagingStandard plain radiographic evaluation involves anteroposterior, lateral, and open mouth views.Cross Table Lateral View (CTLV), which can depict 70 to 79% of all injuries. The lateral film must adequately visualize the entire cervical spine including the cervicothoracic junction. If the lateral view is not sufficient, a swimmer's view is obtained. If still unclear, a computed tomography (CT) scan of C7-T1 is obtained. Anteroposterior (AP) and the open mouth view increases the diagnostic yield of plain radiographs to 90-95%. Radiographs of the thoracic and lumbar spine are indicated for all patients with multiple injuries, patients who are obtunded, and patients with neurologic deficits. On the lateral cervical spine radiograph, one may appreciate:Acute kyphosis or loss of lordosis.Continuity of radiographic lines: anterior vertebral line, posterior vertebral line, facet joint line, or spinous process line.Widening or narrowing of disc spaces.Increased distance between spinous processes or facet joints.Abnormal retropharyngeal swelling, which depends on the level in question:At C1: >10 mmAt C3, C4: >4 mmAt C5, C6, C7: >15 mmRadiographic markers of cervical spine instability, including the following:Compression fractures with >25% loss of heightAngular displacements >11 degrees between adjacent vertebrae (as measured by Cobb angle)Translation >3.5 mmIntervertebral disc space separation >1.7 mm (Figs. 9.2 and 9.3)

Four important lines should be checked (anterior and posterior vertebral lines, spinolaminar line, spinous process line); contour of vertebra and position of spinous process (if deviates to one side implies rotation), distance between spinous processes.Ip, 2008ImagingIp, 2008

CT:Occult fracture (e.g. lateral masses)Degree of retropulsionDouble vertebra sign suggestive of fracture dislocation3D reconstruction, as well as coronal/sagittal reconstructions

ImagingMRI advantages can assess:DiscCord (oedema, bleeding)Ligament (integrity)Haematoma (e.g. epidural)Ip, 2008

Spinal cord injuries without radiographic abnormality (SCIWORA)

Young patients because of the elasticity of their ligamentsA central cord-type injury Should underwent MRIpatients who are completely asymptomatic with no physical findings, normal mentation, and no distracting injuries, proposing that these patients do not require radiological evaluation (Pediatric Trauma, 2006)

Cervical SpineC1 and C2 are referred to as the axial cervical spine C1 ring fractures, (Jefferson), specific patterns of odontoid peg fractures, and specific pedicle (Hangman's) fractures of C2. C3 to C7 represents the subaxial cervical spine.

Handbook of Fracture, 2006Thoraco-lumbar SpineThe essential fracture patterns are wedge, burst, flexion or seatbelt (chance), or fracture dislocations.Compression Fracture

Handbook of fracture, 2006

principles of spine injury management (1) to avoid the progression of neurologic defisit (2) to reduce unacceptable spinal deformity or malalignment (3) to maintain spinal alignment within a functional range (4) to achieve healing of the spine in a functional alignment sufficient to permit return of physiologic loads through the spine.

Trauma, Feliciano, 2008Pharmacologic TreatmentMethylprednisoloneGanglioside GM1NaloxoneMedical TreatmentPatients with acute spinal cord injury should optimally receive methylprednisolone within three hours of the injury for a period of 24 hours.79 Patients with methylprednisolone therapy initiated between three and eight hours from the time of injury, should continue this regimen for 48 hours. Methylprednisolone is widely used in the treatment of acute spinal cord injury and is considered by many as the standard of care.

Dose of Methylprednisolone

Orthopedic Surgery Essential, 2004Immediate spinal immobilizationIn the cervical spine initial immobilization may be achieved with the use of tongs or halo ring tractionThe goals of traction include reduction of the deformity, indirect decompression of the traumatized neural elements, and provisional stability of the spine. The urgency of the reduction is based on experimental studies of spinal cord injuries which suggest a window of six to eight hours during which decompression may reverse neurologic deficitsImmobilization in the thoracolumbar spine may initially be achieved by bed rest and log-rolling the patient. Additionally, these injuries may be stabilized with the use of a rigid brace, which in many instances may also be the definitive treatment.Basic cervical orthoses

SurgeryThe majority of the spine fractures can be treated nonoperatively. Only injuries that are unstable, with or without neurologic involvement, require surgical treatment. Surgical objectives include the correction of spine alignment; the restoration and maintenance of spine stability; and the decompression of compromised neural elements.Timing of SurgeryThe absolute indications for immediate surgery are progressive neurologic deterioration and spine fracture-dislocations associated with incomplete or no neurologic deficit.In the absence of neurologic deficit, it is reasonable to delay surgery to facilitate surgical planning, and allow for spinal cord and nerve root edema to resolve. optimum canal clearance is most effective if surgery is ideally performed within four days