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dr. Muh. Andry Usman, SpOT
Department of Orthopaedic and Traumatology Faculty of Medicine
Hasanuddin University
Spinal injury can lead to spinal cordinjury
Spinalcordinjurycanleadto:ParaplegiaQuadriplegiaDeath
10,00020,000spinalcordinjuriesperyear Incidence~82%occurinmen~61%occurin1630yoa
CommoncausesMVC(48%)Falls(21%)Penetratinginjuries(15%)Sportsinjuries(14%)
40% of trauma patients with neuro decitswillhavetemporaryorpermanentSCI
Many more vertebral injuries that do notresultincordinjury
MostcommonlyinjuredvertebraeC5C7C1C2T12L2
Education inproperhandlingandmovementcandecreaseSCI
PrimaryInjuryPreventionPublicEducationEMSCommunityServiceProjects
SecondaryInjuryPreventionFirstResponderCareEMSCareTertiaryHospitalCare
33VertebraeSpinesupportedbypelvis key ligaments and muscles connect head to
pelvisanteriorlongitudinalligamentanteriorportionofthevertebralbodymajorsourceofstabilityprotectsagainsthyperextension
posteriorlongitudinalligamentposteriorvertebralbodywithinthevertebralcanalpreventshyperexion
BoneStructureoftheSpine
Cervical
Lumbar
Thoracic
Sacral/Coccyx
CervicalSpine7vertebraeveryexibleC1:alsoknownastheatlasC2:alsoknownastheaxis
ThoracicSpine12vertebraeribsconnectedtospineprovidesrigidframeworkofthorax
LumbarSpine5vertebraelargestvertebralbodiescarriesmostofthebodysweight
Sacrum5fusedvertebraecommontospineandpelvis
Coccyx4fusedvertebraetailbone
Vertebral body posterior portion forms part of vertebral
foramen increases in size from cervical to sacral spinous process transverse process
Vertebral foramen opening for spinal cord
Intervertebral disk shock absorber (fibrocartilage)
Ends at ~ L-2 cauda equina
Blood supplied by vertebral and spinal arteries
Gray matter: core pattern\ resembling butterfly
White matter: longitudinal bundles of myelinated nerve fibers
SpinalCordThoracic and lumbar levels supply
sympatheticnervoussystembersCervical and sacral levels supply
parasympatheticnervoussystembers
AscendingNerveTracts(sensoryinput) carry impulses from body structures and sensory
informationtothebrain Posteriorcolumn(dorsal)
conveys nerve impulses for proprioception, discriminativetouch,pressure,vibration,&twopointdiscrimination
crossoveratthemedullafromonesidetotheothere.g.impulsesfromleftsideofbodyascendtotherightsideofthebrain
SpinothalmicTracts(anterolateral)Convey nerve impulse for sensing pain,
temperature&lighttouch Impulses cross over in the spinal cord not the
brainLateraltracts
conduct impulses of pain and temperature to thebrain
Anteriortractscarryimpulsesoflighttouchandpressure
DescendingMotorTracts(motoroutput)ConveysmotorimpulsesfrombraintothebodyPyramidaltracts:Corticospinal&CorticobulbarCorticospinaltracts
destined to cause precise voluntary movement andskeletalmuscleactivity
lateraltractcrossesoveratmedulla
To thalamus and cerebral cortex (sensory)
Brain Stem
Spinal Cord
Pain - Temp Proprioception (conscious)
Spinothalmic tract
Example Motor Pathway (corticospinal tract)
LMN
Motor Cortex
Corticospinal tract
Posterior column
31pairsoriginatefromthespinalcordCarrybothsensationandmotorfunctionNamedaccordingto levelofspinefromwhere
theyariseCervical18Thoracic112Lumbar15Sacral15Coccygeal1
Dermatome Specicareainwhichthespinalnerve
travelsorcontrols Useful in assessment of specic level
SCI Plexus
peripheral nerves rejoin and functionasgroup
CervicalPlexusdiaphragmandneck
LEVEL SENSATION MOTOR REFLEX
C5 Lateral arm (axilarry patch) Deltoid Biceps
C6 Lateral forearm Wrist extension, biceps Brachioradialis
C7 Middle finger Triceps, wrist flexors, finger extension Triceps
C8 Small finger Finger flexors None
T1 Medial arm Interossei None
LEVEL SENSATION MOTOR REFLEX L1 Anterior thigh Psoas (T12,L1,L2,L3) None
L2 Anterior thigh, groin Quadriceps (L2,L3,L4) None
L3 Anterior and lateral thigh Quadriceps (L2,L3,L4) None
L4 Medial leg and foot Tibialis anterior Patellar
L5 Lateral leg and dorsal foot Extensor hallucis longus None
S1 Lateral and plantar foot Gastroenemius, peroneals Achilles
S2-24 Perianal Bladder and foot intrinsics None
Most important spinal injury indicator
Suddendecelerations(MVCs,falls) Compressioninjuries(diving,fallsontofeet/
buttocks) Signicantblunttraumaaboveclavicles Very violentmechanisms (explosions, cave
ins,lightningstrike)
Paininspineorparaspinalarea Pain in back of head, shoulders, arms,
legs Absent, altered sensation (numbness,
paresthesias, loss of temperature,position,touchsense)
Absent , a l tered motor funct ion(weakness,paralysis)
Diaphragmaticbreathing(paralysisofchestwall)
Shockwithslowheartrateanddryskin Incontinence Priapism
Neurologic decits are a result of cordinjury
Spinal injury without cord involvementmay produce no signicant signs andsymptoms
TraditionalApproachBasedonMOIEmphasisonspinalimmobilizationin
unconscioustraumavictimspatientswithamotioninjury
NoclearclinicalguidelinesorspeciccriteriatoevaluateforSCI
Signspain,tenderness,painfulmovementdeformity,injuryoverspinalarea,shockparesthesias,paresis,priapism
ABCsAirwayand/orBreathingimpairmentInabilitytomaintainairwayApneaDiaphragmaticbreathing
CardiovascularimpairmentNeurogenicShockHypoperfusion
NeurologicStatus:LevelofConsciousness
Braininjuryalso?CooperativeNoimpairment(drugs,alcohol)Understands&RecallseventssurroundinginjuryNoDistractinginjuriesNodicultyincommunication
AssessFunction&SensationPalpateovereachspinousprocessMotorfunctionShrugshouldersSpreadngersofbothhandsandkeepapartwith
forceHitchhike{T1}Footplantarexors(gaspedal){S1,2}
Sensation(PositionandPain)weakness,numbness,paresthesiapain(pinprick),sharpvsdull,symmetry
Priapism
ForcesDirecttraumaticinjury
staborgunshotdirectlytothespine
ExcessiveMovement acceleration deceleration deformation
DirectionalForces exion,hyperexion extension,hyperextension rotational lateralbending verticalcompression distraction
Can have spinal column injury with or without
spinal cord injury
PrimaryInjury occursatthetimeof
injury mayresultincordcompressiondirectcordinjury interruptionincord
bloodsupply
SecondaryInjuryoccursafterinitialinjurymayresultfromswelling/inammation ischemiamovementofbody
fragments
Cordconcussion&Cordcontusiontemporarylossofcordmediatedfunction
Cordcompressiondecompressionrequiredtominimizepermanent
injuryLacerationpermanentinjurydependentondegreeof
damageHemorrhagemayresultinlocalischemia
Cordtransection Complete alltractsdisrupted cordmediatedfunctionsbelowtransectionare
permanentlylost determined~24hourspostinjury possibleresults
quadriplegia paraplegia
Paraplegialossofmotorand/or sensory
function in thoracic, lumbaror sacral segments of SC(armfunctionisspared)
Quadriplegialossofmotorand/orsensory
function in the cervicalsegmentsofSC
CordtransectionIncompletesometractsandcordmediatedfunctionsremainintactpotentialforrecoveryoffunctionPossiblesyndromes
BrownSequardSyndrome AnteriorCordSyndrome CentralCordSyndrome Posteriorcordsyndrome
IncompleteCordInjury Injurytoonesideofthecord(Hemisection)Often due to penetrating injury or vertebral
dislocationCompletedamagetoallspinaltractsonaected
sideGoodprognosisforrecovery
ExamFindingsIpsilateral loss of motor function motion,
position,vibration,andlighttouchContralateral loss of sensation to pain and
temperatureBladder and bowel dysfunction (usually short
term)
AnteriorSpinalArterySyndromeSupplies the anterior 2/3 of the spinal cord to
theupperthoracicregioncausedbybonyfragmentsorpressureonspinal
arteries
ExamFindings Variable loss of motor function and
sensitivitytopinprickandtemperature lossofmotorfunctionandsensationtopain,
temperatureandlighttouch Proprioception (position sense) and
vibrationarepreserved
Usuallyoccurswithahyperextensionofthecervicalregion
ExamFindings Weaknessorparesthesiasinupperextremities
butnormalstrengthinlowerextremities varyingdegreeofbladderdysfunction
Injury to nerves within the spinal cord astheyexitthelumbarandsacralregions UsuallyfracturesbelowL2 Specicdysfunctiondependsonlevelofinjury
ExamFindings Flaccidtypeparalysisoflowerbody Bladderandbowelimpairment
Picture 2
TemporarylossofautonomicfunctionofthecordatthelevelofinjuryUsually results from cervical or high thoracic
injuryDoesnot always involvepermanentprimary
injuryEects may be temporary and resolve in
hourstoweeksGoalistoavoidsecondaryinjury
PresentationFlaccidparalysisdistaltoinjurysiteLossofautonomicfunctionhypotensionorrelativehypotensionvasodilation lossofbladderandbowelcontrolpriapism lossofthermoregulationwarm,pink,drybelowinjurysiterelativebradycardiamay have class SNS response presentation above
injury
PrimaryGoalPreventsecondaryinjury
StabilizationofthespinebeginsintheinitialassessmentTreatthespineasalongboneSecurejointaboveandbelow
Cautionwithpartialspinesplinting ImmobilizationvsMotionRestriction
Neutralpositioningofheadandneckifatallpossible allowsforthemostspaceforcord moststablepositionforspinalcolumn dontforceit
CervicalMotionRestriction Manualmethod Rigidcollarcomeslater Interimdevice(KED) Movetolongboardorfullbodyvacuumsplint Manualcontinuesuntiltrunkandheadsecured CIDDontusesandbagsorIVuidbagsasheadblocksTapeworkswonders! Improvisewithblanketrolls
DontforgetthePadding Maintainsanatomicalposition Limitsmovementonboardespeciallyduringtransportonboardorinvehicle
llallthevoids curvatureofthelowerbackisnormalllitpillows,blankets,towelsTapealong(evenducttape)isnotenough
SecuringtotheBoardStraps,Tape,Cravats,whateverTorsorstthenlegsandfeetandhead
EvenpatientsextricatedwithaKEDaresecuredtotheboard
PediatricPatientConsiderationsElevatetheentiretorsoiflargeocciputPadunderneathShortboardunderneathVacuummattress
LotsofvoidstollDiculttondacorrectlysizedrigidcollarImprovisewith
horsecollarblanketortowelrolls
HelmetedPatientsRemovalshouldbelimitedtoemergentneedfor
accesstoairwayandventilationLeaveinplaceifgoodtwithlittleornoheadmovementwithinnoimpendingairwayorbreathingproblemscanperformspinalmotionrestrictionwithhelmetonnointerferenceinairwayassessmentormanagementnocardiacarrest
HelmetedPatientsTypesofHelmetsSports(football,hockey)
ShoulderpadsandhelmetgotogetherRacing(motorcycle,carracer)Recreational(motorcycle,bicycle)
Various helmets create dierent problems forpatientandforremoval
GeneralManualSpinalMotionRestrictionABCs
IncreaseFiO2AssistventilationsprnIVAccess&uidstitratedtoBP~90100mmHg
ConsiderHighDosemethylprednisolone[SoluMedrol]:30mg/kgbolusover15minstheninfusionafter1sthour
Lookforotherinjuries:LifeoverLimbTransporttoappropriateSCIcenter
AbsenceofpainortendernessofthespineLackofneurologicdecitsNormallevelofconsciousness
Includesabilitytounderstandcause&eectAbletomakeownhealthcaredecisions
NoevidenceofalcoholordruguseNodistractinginjuries
Thank You