SPINE

GENERAL INFORMATION

33 Vertebrae: 7 Cervical (lordosis) 12 Thoracic (kyphosis) 5 Lumbar (lordosis) 5 Sacral fused (kyphosis) 4 Coccygeal (fused)

GENERAL INFORMATION (2)Root exit spinal column via intervertebral foramen

C1-7 : exit above their vertebra C8-L5 : exit below their vertebra (C7 exit

above C7 vertebra and C8 exit below C7 vertebra)

Medula spinalis end at L1 (Conus Medullaris)

Lumbar and sacral nerve form cauda equina in spinal canal before exit

DEVIDED INTO 3 COLUMN(DENIS THEORY)

Anterior : 2/3 of vertebral body

Middle : 1/3 of vertebral body

Posterior : Pedicles, lamina, spinous process, and ligament

CERVICAL VERTEBRA (1)

CERVICAL VERTEBRA (2)

THORACAL VERTEBRA (1)

THORACAL VERTEBRA (2)

LUMBAL VERTEBRA

SACRUM AND COXIGEAL VERTEBRA

CORESPONDING STRUCTUREOF VERTEBRA

SPINERADIOLOGY

CERVICAL RADIOLOGY (1)

CERVICAL RADIOLOGY (2)

SWIMMER’S VIEWSENTRASI DAN ARAH SINAR

SWIMMER’S VIEW

• the patient is placed prone on the table with the left arm abducted 180° and the right arm by the side, as if swimming the crawl. The central beam is directed horizontally toward the left axilla. The radiographic cassette is against the right side of the neck, as for the standard cross-table lateral view

To demonstrate : Fractures of C-7, T-1, and T-2

THORACIC RADIOLOGY (1)

• For the anteroposterior view of the thoracic spine, the patient is supine on the table, with the knees flexed to correct the normal thoracic kyphosis. The central beam is directed vertically about 3 cm above the xiphoid process.

THORACIC SPINE(AP VIEW)

1 = pedicle

2 = Paravertebral line

3 = Border of descending aorta

4 = Intervertebral disk

5 = Superior endplate

6 = Inferior endplate

THORACIC RADIOLOGY (2)

• For the lateral view of the thoracic spine, the patient is erect with the arms elevated. To eliminate structures that would obscure the bony elements of the thoracic spine, the patient is instructed to breathe shallowly during the exposure. The central beam is directed horizontally to the level of the T-6 vertebra with about 10° cephalad angulation. The film in this projection demonstrates a lateral image of the vertebral bodies and intervertebral disk spaces.

LATERAL THORACIC SPINE

RIBSPINOUS PROCESS

VERTEBRAL BODY

DISC SPACE

PEDICLE

CLAVICAL

LUMBAL RADIOLOGY (1)

LUMBAL RADIOLOGY (2)

SPINEINJURY

CERVICOCRANIUM INJURY

Measurements for evaluating basilar invagination.

ADI : Atlantodens Interval

SAC : Space Available for the Cord

ATLAS AND ODONTOID FRACTURE

Odontoid Fracture :• Above the base of adontoid (type 1)• At the base (type 2)• Extends into the vertebral body (type

3).

AXIS FRACTURE

Posterior element fracture of C2 the Hangman’s fracture

Compression Fracture Involve anterior half of

vetebral body Treatment :Collar

neck

SUBAXIAL CERVICAL FRACTURE

Anterior compression of C5, wit a fracture of te anterior inferior

aspect.

SUBAXIAL CERVICAL FRACTURE

Burst Fracture Involve whole vetebral

body & have retropulsion into spinal canal

Treatment: ACDF (anterior corpectomy, diskectomy, and fusion ant.plate) VS decompression/post. fusion

CERVICAL BURST FRACTURE

Instability (White and Panjabi) > 3.5 mm of translation

11 degree of kyphotic angulation

(+) strech test

Neuro (cord or root) injury

Anterior elements destroyed

Posterior elements destroyed

Narrow spinal canal

Disc space narrowing

CERVICAL SUBLUXATION AND DISLOCATION

Burst Fracture Involve whole vetebral

body & have retropulsion into spinal canal

Treatment: ACDF (anterior corpectomy, diskectomy, and fusion ant.plate) VS decompression/post. fusion

LUMBAL BURST FRACTURE

Distraction result in complete transverse fracture through entire vetebra.

Note higher effect if anterior longitudinal ligament

LUMBAL

CHANCE FRACTURE

SPINAL CORD INJURY

SPINAL CORD INJURY

ANAMNESIS

Paraparese/paraplegi

Mekanisme trauma

PEMERIKSAAN FISIS

Defisit neurologis atau tidak Spinal shock (+/-) jika Spinal shock (+) Th/ Metilprednisolon (30 mg/KgBB pada jam pertama dilanjutkan 5,4 mg/KgBB/jam selama 23 jam berikutnya)

SPINAL INJURY ALOGARITM

A Thorough neurological examination : sensory and

motory

SPINAL SHOCK (+)

SPINAL SHOCK (-)

Th/ with metilprednisolon Level of SCI

BCR (-) BCR (+)

SCI

SPINAL CORD INJURY

Young males most common

High associaton with C-spine fracture

Classification:

1.Complete : no function below the injury level (spinal shock must be resolved to diagnose)

2.Incomplete

I. Central

II. Anterior

III. Brown-Sequard

IV.Posterior

NORMAL SPINAL CORD

CENTRAL CORD SYNDROME

Central grey matter

Hyperextension mechanical, seen in elderly with cervical spondylosis

Evaluation : Upper Extremity > Lower Extremity Motor Loss

ANTERIOR SPINAL ARTERY SYNDROME

Worst prognosis

Evaluation : Lower Extremity > Upper Extremity motor and sensoris, proprioseptor intact

Spinothalamic and corticospinal tracts out, posterior columns spared

BROWN-SEQUARD SYNDROME

Best prognosis

Usually penetrating trauma, rare injury

Ipsilateral motor loss, contralateral pain/temp loss

Lateral half of spinal cord (“hemisection”)

POSTERIOR COLUMN SYNDROME

NEUROVASCULAREXAMINATION

MOTORIC EXAMINATION

C1 : motor : Gniohyoid, Thyrohyoid, Rectus Capitus

C2 : Motor : Longus colli/capitis C3 : Motor : Diaphragm C4 : Motor : Diaphragm

Note : C1-C4 are not included in examination because of the difficulty of testing them

UPPER EXTREMITY (MOTORIC)

C5 – Shoulder Abduction C6 – Wrist Extension

UPPER EXTREMITY (MOTORIC)

C7 – Wrist flexion and finger extension

UPPER EXTREMITY (MOTORIC)

C8 – Finger flexion

UPPER EXTREMITY (MOTORIC)

T1 – Finger abduction, adduction

LOWER EXTREMITY (MOTORIC)

T12, L1, L2, L3 : Hip Flexion

LOWER EXTREMITY (MOTORIC)

L2, L3, L4 : Knee Extension & Hip Adduction

LOWER EXTREMITY (MOTORIC)

L4 – Foot Inversion

LOWER EXTREMITY (MOTORIC)

L5 – Toe Extension & Hip Abduction

LOWER EXTREMITY (MOTORIC)

S1 – Foot Eversion & Hip Extension

SENSORIC EXAMINATION

SENSORIC EXAMINATION C2 : Sensory : Parietal

scalp

C3 : Sensory : occipital scalp

C4 : Sensory : Base of neck

UPPER EXTREMITY (SENSORIC)

C5 – Lateral arm C6 – Lateral forearm,

thumb, and index finger

C7 : Middle Finger (variable)

C8 : Medial forearm, ring, and small finger

T1 : Medial arm

LOWER EXTREMITY (SENSORIC)

T12 – Lower abdomen just proximal to inguinal ligament

L1 : Upper thigh just distal to inguinal ligament

L2 : mid thigh L3 : Lower thigh

LOWER EXTREMITY (SENSORIC)

L4 - Medial leg, medial side of foot

L5 – Lateral leg, dorsum of foot

S1 – Lateral side of foot

UPPER EXTREMITY (REFLEX)

C5 – Biceps reflex

UPPER EXTREMITY (REFLEX)

C6 – Brachioradialis reflex C7 : Triceps reflex

LOWER EXTREMITY (REFLEX)

L4 – Patellar reflex

LOWER EXTREMITY (REFLEX)

L5 – Tibialis posterior (difficult to obtain)

LOWER EXTREMITY (REFLEX)

S1 – Achilles tendon reflex

SPINALEXAMINATION

SPINAL EXAMINATION (1)

Inspection Gait

Learning foward : spinal stenosis

Wide-based : Myelopathy

Alligment

Malaligment : dislocation, scoliosis, lordosis, kyphosis

Posture

Head tilted : dislocation, spasm, spondylosis, torticolis

Pelvis titled : loss of lordosis (spasm)

Skin (Disrobe patient)

cafe-au-lait spots, growth --> neurofibromatosis

Port wine spots, soft masses --> spina bifida

Palpation Bony structure (Spinous processes)

focal/point tenderness --> fracture Step off -->

dislocation/spondylolithesis Soft tissues

Cervical facet joints : tenderness --> osteoarthritis, dislocation

Coccyx, via rectal exam : tenderness --> fracture or contusion

Paraspinal muscle : difuse tenderness --> sprain/muscle strain, trigger point --> spasm

SPINAL EXAMINATION (2)

Range of motion

Cervical

Flexion : Chin to chest Extension : Occiput back Lateral flexion : Ear to shoulder Rotation : stabilize shoulders -->

rotation Lumbal

Flexion : Touch toes with legs straight

Lateral flexion : bend to each side Rotation : stabilize hip --> rotate

SPINAL EXAMINATION (3)

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