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10/5/17

SPINAL TRAUMA
?
Arwinder Singh

Spinal Trauma Cervical X-Ray


Prinsip : ABCD with C-spine control Indikasi
radiological clearance untuk GCS <15
GCS 15 +
Trauma berat / multipel
Mekanisme
Penurunan kesadaran Defisit Neurologis
Defisit neurologis Nyeri Leher
Jejas Leher
Defisit non neurologis
Pola nafas abdominal
Priapismus

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Spinal Cord Injury Classification


Quadriplegia :
injury in cervical region
all 4 extremities affected

Paraplegia :
injury in thoracic, lumbar or sacral segments
2 extremities affected

Injury either: Complete:


i) Loss of voluntary movement of parts
1) Complete innervated by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
2) Incomplete

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Incomplete:

i) Some function is present below site of


injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although
they are rarely pure and variations occur

What is an incomplete lesion? Muscle Strength Grading:


5 Normal strength
4 Full range of motion, but less than
normal strength against resistance
3 Full range of motion against gravity
2 Movement with gravity eliminated
1 Flicker of movement
0 Total paralysis

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What is the difference between spinal Spinal Shock vs Neurogenic Shock


shock and neurogenic shock?
Spinal Shock :

Spinal shock is mainly a loss of reflexes (flaccid Transient reflex depression of cord function below level of
paralysis) injury
Neurogenic shock is mainly hypotension and Initially hypertension due to release of catecholamines
Followed by hypotension
bradycardia due to loss of sympathetic tone Flaccid paralysis
Bowel and bladder involved
Sometimes priaprism develops
Symptoms last several hours to days

Neurogenic shock: Loss of vasomotor tone pooling of blood


Triad of i) hypotension Loss of cardiac sympathetic tone bradycardia
ii) bradycardia Blood pressure will not be restored by fluid infusion
alone
iii) hypothermia Massive fluid administration may lead to overload
More commonly in injuries above T6 and pulmonary edema
Secondary to disruption of sympathetic Vasopressors may be indicated
outflow from T1 L2 Atropine used to treat bradycardia

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Types of incomplete injuries


i) Central Cord Syndrome i) Central Cord Syndrome :

ii) Anterior Cord Syndrome


Typically in older patients
iii) Posterior Cord Syndrome Hyperextension injury
Compression of the cord anteriorly by
iv) Brown Sequard Syndrome osteophytes and posteriorly by ligamentum
flavum
v) Cauda Equina Syndrome

Also associated with fracture dislocation and


compression fractures
More centrally situated cervical tracts tend to
be more involved hence
flaccid weakness of arms > legs
Perianal sensation & some lower extremity
movement and sensation may be preserved

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ii) Anterior cord Syndrome:


Due to flexion / rotation
Anterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal
Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia
of blood supply (anterior spinal arteries)

Clinically:
Loss of power
Decrease in pain and sensation below lesion
Dorsal columns remain intact

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ii) Posterior Cord Syndrome:


Hyperextension injuries with fractures of
the posterior elements of the vertebrae

Clinically:
Proprioception affected ataxia and
faltering gait
Usually good power and sensation

iv) Brown Sequard Syndrome: Clinically:


Hemi-section of the cord Paralysis on affected side (corticospinal)
Either due to penetrating injuries: Loss of proprioception and fine discrimination
i) stab wounds (dorsal columns)
ii) gunshot wounds Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
Fractures of lateral mass of vertebrae

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v) Cauda Equina Syndrome:


Due to bony compression or disc protrusions
in lumbar or sacral region

Clinically
Non specific symptoms back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia

Initial Management Management in the hospital


Immobilization NGT to suction
Rigid collar Prevents aspiration
Decompresses the abdomen (paralytic ileus is common in the first
Sandbags and straps days)
Spine board Foley
Log-roll to turn Urinary retention is common
Prevent hypotension Methylprednisolone (Solu-Medrol)
Only if started within 8 hours of injury
Pressors: Dopamine, not Neosynephrine
Exclusion criteria
Fluids to replace losses; do not overhydrate Cauda equina syndrome
Maintain oxygenation GSW
Pregnancy
O2 per nasal canula Age <13 years
If intubation is needed, do NOT move the neck Patient on maintenance steroids

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CT scan MRI
Good in acute situations Almost never an emergency
Shows bone very well Exception: cauda equina syndrome
Sagittal reconstruction is mandatory Shows tumors and soft tissues (e.g., herniated
Soft tissues (discs, spinal cord) are poorly discs) much better than CT scan
visualized May be used to clear c-spine in comatose
Do NOT give contrast in trauma patients patients
(contrast is bright, mimicking blood)

Cervical Traction Gardner-Wells tongs


Gardner-Wells tongs
Provides temporary stability of the cervical spine
Contraindicated in unstable hyperextension injuries
Weight depends on the level (usually 5lb/level, start with
3lb/level, do not exceed 10lb/level)
Cervical collar can be removed while patient is in traction
Pin care: clean q shift with appropriate solution, then apply
povidone-iodine ointment
Take XRays at regular intervals and after every move from bed

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Surgical Decompression and/or Fusion


Indications
Decompression of the neural elements (spinal
cord/nerves)
Stabilization of the bony elements (spine) Traumatic Fracture Dislocatio L1

Timing
Emergent
Incomplete lesions with progressive neurologic deficit
Elective
Complete lesions (3-7 days post injury)
Central cord syndrome (2-3 weeks post injury)

Post Pedicle screw fixation + Laminectomy

Soft and hard collars


Fracture & Dislocatio C5-6

Lateral mass plating


Pre OP

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Minerva vest and halo-vest Long term care


Rehab for maximizing motor function
Bladder/bowel training
Psychological and social support

thank you

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