TRAUMA SARAF SPINALTRAUMA SARAF SPINALTRAUMA SARAF SPINALTRAUMA SARAF SPINALWiryawan Manusubroto

SpB,SpBS(K)SMF Bedah Saraf RSUP dr Sardjito

INTRODUCTIONINTRODUCTION

ANATOMY PHYSIOLOGYANATOMY PHYSIOLOGY

Spinal cord ends at L1

Three tracts can be readily assessed clinically.- The corticospinal tract- The spinothalamic tract- The spinothalamic tract- The posterior columns

Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury: If any motor or sensory function remains, prognosis for recovery is much better.

– Thoracic and lumbar levels supply sympathetic nervous system fibers

– Cervical and sacral – Cervical and sacral levels supply parasympathetic nervous system fibers

Dermatomes and Dermatomes and MyotomeMyotome

PATHOLOGY OF SCIPATHOLOGY OF SCI

� Primary Injury ◦ occurs at the time of injury

◦ may result in

� Secondary Injury◦ occurs after initial injury

◦ may result from◦ may result in � cord compression

� direct cord injury

� interruption in cord blood supply

◦ may result from� swelling/inflammation

� ischemia

� movement of body fragments

� Cord transection◦ Complete

� all tracts disrupted

� cord mediated functions below transection are permanently lost

CLINICAL CLASSIFICATIONCLINICAL CLASSIFICATION

permanently lost

� determined ~ 24 hours post injury

� possible results◦ quadriplegia

◦ paraplegia

� Cord transection◦ Complete

� all tracts disrupted

� cord mediated functions below transection are permanently lostpermanently lost

� determined ~ 24 hours post injury

� possible results◦ quadriplegia

◦ paraplegia

� Cord transection◦ Incomplete

� some tracts and cord mediated functions remain intact

� potential for recovery of � potential for recovery of function

� Possible syndromes◦ Brown-Sequard Syndrome

◦ Anterior Cord Syndrome

◦ Central Cord Syndrome

� Incomplete Cord Injury◦ Injury to one side of the cord (Hemisection)

◦ Often due to penetrating injury or vertebral dislocation

Brown Brown SequardSequard SyndromeSyndrome

dislocation

◦ Complete damage to all spinal tracts on affected side

◦ Prognosis for recovery is variable

� Exam Findings◦ Ipsilateral loss of motor function motion, position, vibration, and light touch

◦ Contralateral loss of

Brown Brown SequardSequard SyndromeSyndrome

◦ Contralateral loss of sensation to pain and temperature

◦ Bladder and bowel dysfunction (usually short term)

� Anterior Spinal Artery Syndrome◦ Supplies the anterior 2/3 of the spinal cord to the upper thoracic region

Anterior Cord SyndromeAnterior Cord Syndrome

region

◦ caused by bony fragments or pressure on spinal arteries

� Exam Findings◦ Variable loss of motor function and sensitivity to pinprick and temperature

◦ loss of motor function and sensation to pain, temperature

Anterior Cord SyndromeAnterior Cord Syndrome

pain, temperature and light touch

◦ Proprioception (position sense) and vibration are preserved

� Usually occurs with a hyperextension of the cervical region

� Exam Findings◦ weakness or paresthesias in upper

Central Cord SyndromeCentral Cord Syndrome

paresthesias in upper extremities but normal strength in lower extremities

◦ varying degree of bladder dysfunction

� Injury to nerves withinthe spinal cord as theyexit the lumbar andsacral regions◦ Usually fractures below L2

◦ Specific dysfunction depends on level of injury

� Exam Findings

CaudaCauda EquinaEquina SyndromeSyndrome

� Exam Findings◦ Flaccid-type paralysis oflower body

◦ Bladder and bowel impairment

� Temporary loss of autonomic function of the cord at the level of injury

◦ Usually results from cervical or high thoracic injury

� Effects may be temporary and resolve in hours to weeks

� Presentation

◦ Flaccid paralysis distal to injury site

◦ Loss of autonomic function

� hypotension or relative hypotension

NeurogenicNeurogenic ShockShock

� hypotension or relative hypotension

� vasodilation

� loss of bladder and bowel control

� priapism

� loss of thermoregulation

� warm, pink, dry below injury site

� relative bradycardia

Effect on other Effect on other Organ SystemsOrgan Systems

� Hypoventilation due to the paralysis:�Intercostal muscles�Diaphragm

� The inability to perceive pain may mask a � The inability to perceive pain may mask a potentially serious injury elsewhere: ◦ Abdominal injury – no abdominal tenderness◦ Lower extremity injury

� Compression

� Flexion

� Extension

� Rotation

� Lateral bending

Distraction

Mechanism Of InjuryMechanism Of Injury( High Energy )( High Energy )

� Distraction

� Penetration

� Rearback - Fall > 10 feet

� ABCs�Airway and/or Breathing � Inability to maintain airway

� Apnea

� Diaphragmatic breathing

� Cardiovascular impairment

� Shock◦ Hypotension and or bradycardia

GENERAL ASSESMENTGENERAL ASSESMENT

◦ Hypotension and or bradycardia◦ Patient appears warm and dry

� Hypoperfusion

� Level of consciousness

� Inspection and palpation: Occiput to Coccyx◦ Tenderness to the vertebrae◦ Gap or Step-off (both very rare)◦ Edema and bruising◦ Spasm of associated muscles

� Neurological assessment◦ Motor ◦ Sensation

CLINICAL EVALUATIONCLINICAL EVALUATION

◦ Motor ◦ Sensation◦ Reflexes

� NEXUS Criteria:1. Absence of tenderness in the posterior midline

2. Absence of a neurological deficit3. Normal level of alertness (GCS score = 15)

NEXUSNEXUS

15)4. No evidence of intoxication (drugs or alcohol)

5. No distracting injury/pain

� Any patient who fulfilled all 5 of the criteria were considered low risk for C-spine injury and as such did not need C-spine radiography

� For patients who had any of the 5 criteria,radiographic imaging was indicated in

NEXUSNEXUS

radiographic imaging was indicated in theform of AP, lateral, and odontoid C-spine views

Imaging OptionsImaging Options

� Initial Screening Options:◦ Plain films– Lateral, AP, and Odontoid, � Optional: Oblique and Swimmer’s (if necessary)

◦ CT- much better than plain films for bony fractures/dislocations. Poor evaluation of ligamentous injuries.

� Other cervical spine imaging options◦ MRI- Very good for soft tissue/ligamentousinjuries.

◦ Flexion-Extension Plain Films- to determine stability (may replace MRI if unavailable or contraindicated)

AP/LATERAL/SPECIAL VIEWAP/LATERAL/SPECIAL VIEW

� Anterior subluxation of one vertebra on another indicates facet dislocation

� Less than 50% of the width of a vertebral body implies unifacet dislocationof a vertebral body implies unifacet dislocation

� Greater than 50% implies bilateral facet dislocation

� This is usually accompanied by widening of the interspinous and interlaminar spaces

X-ray Guidelines (cervical)

Mnemonic AABBCDS

� Adequacy, Alignment

� Bone abnormality, Base of skull

� Cartilage,

� Disc space

Soft tissue

Radiological EvaluationRadiological Evaluation

� Soft tissue

� Thin cut CT scanning should be used to evaluate abnormal, suspicious or poorly visualized areas on plain radiology

� The combination of

CT ScanningCT Scanning

� The combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%

� Ideally all patients with an abnormal neurological examination should be evaluated with an MRI scan

� Patients who report transient neurological

MRIMRI

transient neurological symptoms but who have a normal exam should also undergo an MRI assessment of their spinal cord

Spinal injuries can be described as,� Fractures � Fracture dislocations� SCIWORA � Penetrating injuriesInjuries can be stable or unstable

MorphologyMorphology

Injuries can be stable or unstableAll patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury until proven otherwise.

Stable Stable vsvs Unstable Fractures Unstable Fractures

� Stability of cervical spine is provided by two functional vertical columns◦ Anterior column: vertebral bodies, the disc spaces, the anterior and posterior longitudinal ligaments and annulus fibrosusligaments and annulus fibrosus

◦ Posterior column: pedicles, facets and apophyseal joints, laminar spinous processes and the posterior ligament complex

� As long as one column is intact the injury is stable.

� Primary Goal◦ Prevent secondary injury

� Stabilization of the spine begins in the initial assessment◦ Treat the spine as a long bone

MANAGEMENT OF CORDMANAGEMENT OF CORD

◦ Treat the spine as a long bone

� Secure joint above and below

◦ Caution with “partial” spine splinting

� Immobilization vs Motion Restriction

� General Precaution◦ Spinal Motion Restriction: immobilization devices

◦ ABCs

� Increase FiO2

� Assist ventilations as needed with cervical spine control

� Indications for intubation:acute respiratory failure, Glasgow score <9, increased respiratory rate with hypoxia, PCO2 score <9, increased respiratory rate with hypoxia, PCO2 more than 50, and vital capacity less than 10 mL/kg

� IV Access & fluids titrated to BP ~ 90-100 mm Hg

◦ Look for other injuries: “Life over Limb”

◦ Transport to appropriate SCI center once stabilized

� Consider High Dose methylprednisolone: ◦ 30 mg/kg bolus over 15 mins

◦ After bolus: infusion 5.4mg/kg IV for 23 hours

◦ Controversial as recent evidence questions benefitbenefit

◦ Must be started < 8 hours of injury

◦ Most spine surgeons do not use for penetrating trauma

TRAUMA : MECHANISM ?

ABC AND D

PEX

ALERT

‘UNCONSIOUSNESS’

( NEED ICU/INTUBATED)

D

FLOWCHART FLOWCHART 11

CARDINAL SSX-

NO NEED IMAGING

A

SSX+

(IF PLEGIA , DISTINCT FROM SPINAL SHOCK)

B

D

SSX IS UNCLEAR

CLARIFY !

SSX+

( > + 1 )

IMAGING

AP,LAT,SPESIFIC

PLAIN X RAY

PLAIN X RAY

FLOW CHART BFLOW CHART B

PLAIN X RAY NEGATIF

PLAIN X RAY POSITIF

C

CLEARENCEBY EXPERT/CT/MRI

STABEL UNSTABEL

VASCULAR PROBLEM ?

STABEL

IS DECOMPRESSION

NEEDED

UNSTABEL

STABILIZING

FLOWCHART CFLOWCHART C

STABILIZING IS PURSUIT DEPEND

ON LAST CONDITION OF

STABILITY

DECOMPRESSION IF NEEDED

ENTIRE SPINAL EVALUATION

� AP/LAT CERVICAL

� 3 D CT CERVICAL-THORACAL

� AP/LAT THORACOLUMBAR

FLOWCHART DFLOWCHART D

Points to Remember:Points to Remember:

� Maintain cervical spine immobilization until spine properly evaluated

� Criteria exist (NEXUS ) that identify the need for cervical spine imaging◦ Patients negative for either criteria may ◦ Patients negative for either criteria may have their spine clinically cleared

� Screen patients with plain radiograph or CT◦ CT better than plain radiographs

MATUR NUWUNMATUR NUWUN