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DR.HAFIZ-UR- REHMAN
Assistant Professor orthopaedic surgery
Postal address
Orthopaedic Clinic APWA Medical Complex
Ground Floor (Opposite: I B A & Ankal Seria Hospital)
GARDEN ROAD, SADAR, KARACHI- PAKISTAN.
Cell no. 0092 331 3 50 30 55 Email: [email protected],
Spinal injuries
ORTHO PAEDICS
Nicholas Andry a French physcianin 1741 credited for coining the term, orthopaedics from two words
Ortho = striaght
Paedics = child.
HISTORY ( His /Her + Story)
GENERAL PHYSICAL EXAMINATION
SYSTEMIC EXAMINATION
LOCAL EXAMINAION
INVESTIGATION
DIAGNOSIS
? ?
Spinal injuries
Important StructuresThe important parts of the cervical spine include bones joints nerves connective tissues muscles & spinal segments .
Trauma is the study of medical problems associated with physical injury.
The injury is the adverse effect of a physical force upon a person.
Bone is specialised connective tissue, providing a rigid skeleton,an important shape,protecting vital structures, mineral storage house and muscles attachment which move joints on their actions.
Suprior surface of the Atlas . C1 Nerve divides into
anterior & posterior rami just behind the Atlanto
occipital joint, lies in the groove beneath the
Vertebral artery.
CERVICAL SPINAL VERTEBAE
The cervical spine is the most mobile area of the spine, and as such it is prone to the greatest number of injuries.
Injuries to the cervical spine and spinal cord are also potentially the most devastating and life altering of all injuries compatible with life.
Spinal injuries carry a double threat: damage
to the vertebral
column and damage to
the neural tissue.
INCIDENCE of spinal cord injury range from 27 to 47 cases per million population per year. In the world. Road traffic accident is leading cause of spinal injuries.Pre- hospital survival and life expectancy of spinal cord injury victims have improved.
United States 10,000 spinal cord injuries occur each year. 80% of the victims are younger than 40 years.80% of all people who suffer from spinal column injuries are male. 60% of injuries to the vertebral column in patients older than 75 years are presented with h/o fall.
00.5
11.5
22.5
33.5
In younger patients, 45% of injuries result from motor vehicle accidents, 20% from falls, 15% from sports injuries, 15% from acts of violence, and the remainder from other causes.
Pre- hospital survival and life expectancy of spinal cord injury victims have improved.
Why ? How?
Patients with cervical spine injuries are dying secondary to respiratory complications.
The approach in treating these patients is early recognition of cervical spine injuries with rapid immobilization to prevent neurologic deterioration while the evaluation and treatment of associated injuries are carried out.
After the patient is stabilized,
the goals are restoration and maintenance of spinal alignment to provide stable weight bearing and facilitate rehabilitation.
A T L S-------------------ABCD
Mechanism of acute traumatic injuries
.
Mechanism of injury The spine is usually injured in one of two ways: (a) a fall onto the head or the back of the neck; and (b) a blow on the forehead, which forces the neck into hyperextension. Fractures may occur with minimal force in osteoporotic or pathological bone.
Indirect injuries usually occur when the spinal column collapses in its vertical axis, typically in a fall from a height or when someone is trapped under a cave in; the direction of force at any level of the spine is determined by the position of the vertebral column at the moment of impact. The flexible cervical and lumbar segments may also be injured by violent free movements of the neck or trunk.or a sudden jerk of the neck following a rear-
end collision (whip-lash injury
The important types of displacement are: (1) hyperextension; (2) flexion; (3) axial compression; (4) flexion and compression combined with posterior distraction; (5) flexion combined with rotation and shear; and (6) horizontal translation.
. However, there is always the fear that
movement may cause or aggravate the neural
lesion;
hence the importance of defining these injuries
as stable or unstable.
Cervical Spinal immobilisation
Spinal log roll.
Stable and unstable injuriesthese terms have specific meanings: a stable injury is one in which the vertebral components will not be displaced by normal movements so that an undamaged cord is not in danger;
an unstable injury is one in which further displacement may occur.
. The three elements are:
the posterior complex,
the middle component
and the anterior column.
This concept is particularly useful in assessing the stability of lumbar injuries.
Denis’ classification of the structural elements of the spine
the posterior complex
the middle compo-nent
the anterior column
In assessing spinal stability, three osseo ligamentouscomplex consisting of the pedicles, facet joints, posterior bony arch, and interspinous and supraspinous ligaments;
a middle component consisting of the posterior third of the vertebral body, the posterior part of the intervertebral disc and the posterior longitudinal ligament;
and the anterior column made up of the anterior two-thrids of the vertebral body, the anterior part of the intervertebral disc and the anterior longitudinal ligament. Denis has suggested that, for instability to occur, both posterior and middle elements have to be disrupted; this is true particularly of the thoracolumbar spine.
Fortunately, only 10% of spinal fractures are unstable and less than 5% are associated with cord damage,
DiagnosisEvery patient who has suffered a major accident should be fully examined
his clothes may have to be cut from his body
with the least possible disturbance of position.
With an unconscious patient, awareness is everything; the force producing a serious head injury may also injure the neck
Any complaint of pain or stiffness in the neck or back should be taken seriously, even if the patient is walking- or moving without apparent difficulty.
With the patient supine, the chest and abdomen can be examined for associated injuries. Next the limbs are quickly examined for evidence of neurological damage. To examine the back, the patient is turned onto one side with extreme care using a log-rolling technique.
The spinous processes are carefully palpated.Sometimes a gap can be felt where ligaments are torn; this, or a haematoma over the spine, is a sinister feature.
The bones and soft tissues are gently tested for tenderness. Movement of the spine can be dangerous avoided until a diagnosis has been made. A full neurological examination is carried out in every case; this may have to be repeated several times during the first few days.
Initially, during the phase of spinal shock, there may be complete paralysis and loss of sensation below the level of injury. This may last for 48 hours or longer and during this period it is difficult to tell whether the neurological lesion is complete or incomplete. It is important to test for the primitive anal skin reflex and for perianal sensation. Once the primitive reflexes return, spinal shock has ended; if there is still loss of all motor and sensory function the neurological lesion is complete.Intact perianal sensation a suggests an incomplete lesion, and further recovery may occur.
Imaging The x-ray examination is crucial. It should be carried out with the least possible manipulation of the neck or back, yet it must be complete enough to provide the essential information.
Lateral views of the cervical spine must include all the vertebrae from C1 to T1; unless the vertebrae are actually counted, a low injury may be missed.
Anteroposterior views must include the odontoid process.
Oblique views also may be necessary and it should be remembered that more than one area of the spine may be damaged.
CT Scan is invaluable for showing fractures of the vertebral body or the neural arch, or encroachment on the spinal canal.
MRI is helpful in displaying the soft tissues (intervertebral discs and ligamentum flavum) and lesions in the cord.