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5 jam SMRS saat pasien sedang menebang kayu, kayu terjatuh dan
mengenai punggungnya. Pasien kemudian mengeluhkan tidak bisa
menggerakkan kedua kakinya.
S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)
Traumatic Spondylolisthesis of 1st lumbar spine with Neurologic Deficit TLICS 8
with Spinal Cord Injury of 11th thoracic spine (ASIA-A)
S, M, 23 y.o
Occupation : Carpenter
Mechanism of injury : Work related injury (Hit by a fallen tree)
Traumatic Spondylolisthesis of 1st lumbar spine with Neurologic Deficit TLICS 8
with Spinal Cord Injury of 11th thoracic spine (ASIA-A)
• United States who currently have around 253,000 cases with 11,000 new cases/
year devastating disabilities
• ± 4000 years later, the treatment of SCI remains largely palliative patient
support and managing disability
Function:
Support the axial musculature and protect the spinal cord and nerve root
Respect the structure Disruption creates instability
BIOMECHANICALLY SC injury
Ascending tract:
• Dorsal column: deep touch,
proprioception, vibration
• Lateral spinothalamic: pain,
temperature
• Ventral spinothalamic: light touch
Descending tract:
• Lateral corticospinal: main voluntary motor
• Ventral corticospinal: voluntary motor
Pathophysiology
• When the spinal cord is lacerated or macerated by a
sharp penetrating force, contused or compressed by a
blunt force (DeVivo et al., 2002):
• Primary injury mechanical injury
• Secondary injury (Response following injury)
cascade of biological event
Schematic representation
adapted from Yiu and He (2006).
Identification and Diagnosis
Identification and Diagnosis
Identification and Diagnosis
~48-72 hours
Following excessive
Time immediately after
blood loss
spinal cord injury
Disruption of
autonomic pathway
Decreased preload
leads to loss of
Mechanism leads to decreased
sympathetic tone and
cardiac output.
decreased systemic
vascular resistance.
Treatment
of neurogenic shock is pharmacologic intervention to augment
peripheral vascular tone.
Physical Examination in Spine
• Know the mechanism of injury (low, moderate or high)
• Evaluate injuries to the head, chest, abdomen and pelvis
• Special precautions
(awareness of other injury, e.c calcaneus fracture, thoracal and
abdominal injury, ‘paper bag phenomen’)
Physical Examination in Spine
• Assess the patients symptoms
• Perform logroll Look, Feel and Move
• Look for malalignment/ step off
• Look for tenderness
• Check the neurologic function (ASIA American Spinal lnjury Association/ ASIA
Score)
• Make the spine fracture diagnosis (in trauma settings)
Identification and Diagnosis
(Spinal Cord Injury)
Spinal Shock
Spinal shock is defined as spinal cord dysfunction based on physiologic rather than
structural disruption. Resolution of spinal shock may be recognized when reflex
arcs caudal to the level of injury begin to function again, usually within 24 hours of
injury.
Complete spinal cord injury is defined by the total absence of sensory and motor
function below the anatomic level of injury in the absence of spinal shock
Incomplete spinal cord injury is present when residual spinal cord and/or nerve
root function exists below the anatomic level of injury
Identification and Diagnosis
(Spinal Cord Injury)
Spinal Cord
Injuries
Complete Incomplete
Injury Injury
Incomplete Spinal Cord Injury
Spine Fractures
Stable Unstable
Vertebral components
Significant risk of
will not be displaced
displacement and
by normal
neural tissue damage
movements
Identification and Diagnosis
(Spine Fractures)
Identification and Diagnosis
(Spine Fractures)
• It is not that the RCTs conclusively demonstrate that steroids do not work
in SCI. It is that there is no RCT data suggesting that steroid is effective in
SCI (Cheung et.al., 2015)
Embryonal (ESCs) pre-differentiation protocol is remyelination and functional recovery Liu et al., 2000; McDonald
et al., 1999
performed (neurons,oligodendrocytes
progenitor cells )
Concern: ethical, safety (report on teratoma (Li et al., 2008).
Mesenchymal (MSCs) Isolated from bone marrow, adipose, 43 studies analyzed ± 50% of the experimental studies (Tetzlaff et al., 2010).
umbilical cord (Wharton's Jelly) origin SCI models led to motor improvements. The potential
transdifferentiation into neurons and mechanism unknown
glia cells
No serious complications were reporte(Geffner et al., 2008; Sykova´ et al., 2006a; Yoon et al., 2007)
Stem cell in SCI
The function of stem cell :
1. Neuroprotective to limit secondary tissue loss and the loss of
function
2. Replace and restore of damaged axon and glia
3. Creates favorable microenvironment
Type Function
Neural stem cells Isolated from embryonic or adult spinal cord and multipotent cells with the ability to
(NSCs) brain (dentate gyrus and subventricular zone), differentiate into neurons, oligodendrocytes, and
astrocytes.
Limitation in translational studies practical issues hindering their isolation and ethical concerns
Induced Pluripotent pluripotent cells could be obtained from fibroblast Cell reprogramming by introduction
of 4 (Takahashi and Yamanaka,
Stem cells (iPS) by the introduction of 2006)
four genes into cells via retrovirus-mediated gene transcription factors,OCT3/4 (octamer-
transfer 4), SOX2 (sex-determining region
Ybox2),
KLF4 (Kruppel-like factor), and MYC
(+) They circumvent the ethical concerns associated with ES cells and allow autologous transplantations of pluripotent
cells
iPS and ESCs cells also share similar disadvantages such as the ability to form teratomas (Takahashi and Yamanaka,
2006).
3 months post
5 months post
• Male, 62 y.o
• DIAGNOSIS (2 years post injury and surgery)
• Spinal cord injury at the level of 2nd lumbar spine
• ASIA impairment scale A
Perkembangan Fungsi Motorik Paska
Injeksi Sel Punca Mesenkimal
4 4 4
3 3 3 3 3 3
1 1
0 0 0 0 0
C5 C6 C7 C8 T1 L2 L3 L4 L5 S1
Fungsi Motorik Baseline Fungsi Motorik Paska Injeksi
Current Management
• Another type of approach is tissue
engineering, using biomaterials to help
scaffold and rebuild damaged tissues.
• Further study is evolving and will give better future for the patients