TRAUMA MEDULA SPINALIS

Dr. Rendra leonas SpOT

ORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY MOH. HOESIN PALEMBANG

Introduction
Most common age and high speed level
traffic accident >> 80% spinal inj not assoc SI more important preliminary care

At least 5% of patients With spinal cord injuries Worsen neurologically at hospital.

Introduction

Trauma spine can cause damaged : Hard tissue : bone Soft tissue : ligament discus spinal cord

Introduction

Careful Physical Examination is potentially the most valuable service a physician can provide to the patient. ( OKU Spine : 2004 )

Complete exam : Correct diagnosis Magnitude of the problem Determine appropriate Treatment

Anatomy and Physiology

33 bones comprise the spine

Function

Skeletal support structure Major portion of axial skeleton Protective container for

spinal cord

Vertebral Body

Major weight-bearing component Anterior to other vertebrae components

Anatomy and Physiology

Characteristic of the Vertebrae Cervical
C-1 & C-2 no vertebral body Support head Allow for turning of head Vertebral body size increase inferiorly they become

Anatomy and Physiology

Characteristic of theVertebrae Lumbar spine has strongest and largest weight bearing of the body Sacral & Coccyx vertebrae are fused No vertebral body

Anatomy and Physiology

Components of Vertebrae

Spinal Canal

Opening in the vertebrae that the spinal cord passes through Thick, bony structures that connect the vertebral body to the spinous and transverse processes

Pedicles

Anatomy and Physiology

Components of Vertebrae

Laminae

Posterior bones of vertebrae that make up foramen

Spinous Process

Posterior prominence on vertebrae

Intervertebral Disks

Cartilagenous pad between vertebrae Serves as shock absorber

Transverse Process

Bilateral projections from vertebrae Muscle attachment and articulation location with ribs

Intervertebral Disc
nucleus pulposus annulus fibrosus hyaline cartilage end plates

Facet Joints

Act to limit shear and torsion motions between vertebrae Orientation of facet changes along length of spine Cervical : couple lateral bending and torsional motion Thoracic : coronal plane orientation of joint surfaces Lumbar : sagital plane orientation of joint surfaces Facets carry 10-20% of compressive load in upright standing, >50% of anterior shear load in forward fexion

Anatomy and Physiology

SPINAL NERVES 31 pairs of spinal nerves :
8 cervical 12 thoracic 5 lumbar 5 saccral 1 coccygeal

Each has both motor and sensory fibers

Motor fibers = anterior or ventral root Sensory fibers = posterior or dorsal root

OVERVIEW

LOOK

inspection

FEEL

palpation
active & passive movements

MOVE

EXAMINATION : STANDING
Look :
bruise hematom wound : gun shoot wound stab wound
Deformity

EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral Bony prominence or steps spinous processes

using C7 &/or L4-5 as landmarks approx. 2cm lateral to spinous processes

facet joints

EXAMINATION : STANDING
Feel :
assess alignment, mobility & tenderness of: transverse processes of vertebrae lateral to spinous processes

EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral Bony prominence or steps spinous processes

using C7 &/or L4-5 as landmarks approx. 2cm lateral to spinous processes

facet joints

EXAMINATION : STANDING
Feel :
assess alignment, mobility & tenderness of: transverse processes of vertebrae lateral to spinous processes

Signs of nerve root compression

Standard full neurological examination of both lower limbs :

tone, power (MRC grading) sensation (light touch, pinprick & proprioceptive if indicated) reflexes (physiologic and patologic) an anatomical distribution [dermatome(s) or myotome(s)]

Neurological Examination

Objectives :
Determine if defect is present Localize the level of the deficit

Include :
Sensory Motor Reflex

Neurological Examination
Sensory examination

Explain, eyes closed Examine : touch, 2 point discrimination, proprioceptive. Sensory dermatomes, compare each opposite

Sensory Dermatome

Muscle Power Grading

0 - complete paralysis 1 - flicker of contraction possible 2 - movement is possible when gravity is excluded 3 - movement is possible against gravity 4 - movement is possible against gravity + some resistance 5 - normal power

Neurological Examination
Motor examination

Muscle grading Compare each side

Cervical :
Scapular Deltoid & Biceps C4 C5

Wrist extension & supination

Wrist flexion & Pronation

C6
C7

Neurological Examination
Motor examination

Hip flexor Hip extensor

Lumbo-sacral

L 1,2,3 S1

Knee flexor Knee extensor Ankle flexor Ankle extensor

L 4,5, S1,2 L 2,3,4 S1 L5

Reflexes
Biceps Triceps

Brachioradialis

Hoffman

PROVOCATIVE TESTS TEST

SLR : sitting & supine

COMMENTS
Must produce radicular symptom in the distribution of the provoked root, for sciatic nerve , that means pain distal to knee

Lasgue's sign

SLR radiculopathy aggravated by ankle dorsoflexion

Contralateral SLR

Well-leg SLR puts tension on involved root from opposite direction

Kernig's test

The neck is flexed chin to chest. The hip is flexed to 90, and then the leg is the extended similar to SLR; radiculopathy is reproduced

Bowstring sign

SLR radiculopathy aggravated by applying pressure over popliteal fossa.

Femoral stretch test

Prone patient; examiner stretch femoral nerve roots to test L2-L4 irritation

Nafziger's test

Compression of neck vein for 10 s with patient lying supine ; coughing then reproduces radiculopathy

Milgram's test

Patient raises both legs off the examining table and hold this

position for 30 s; radiculopathy maybe reproduced

Denis 3 Column Theory

Denis, F.: The Three-Column Spine and its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)

Basic Types of Spine Fractures

1. 2.

Compression fracture Burst fracture

Denis Classification

Basic Types of Spine Fractures

3.

Seat-belt injury (Flexion-distraction injury)

Bony Chance fracture

Soft tissue Chance injury

Basic Types of Spine Fractures

4.

Fracture-dislocation

Anterior posterior shear

Flexion-rotation

Flexion-distraction

Classification spine fracture

Stable injury :

compression fracture
burst fracture

Unstable injury : dislocation

fracture dislocation chance fracture

Classification spine fracture

Location : 1. Jefferson fracture 2. Dens fracture 3. Hangmans fracture 4. Clay shovelers fracture 5. SCIWORA

Compression fracture

Failure of the anterior column Mechanism anterior or lateral flexion Normally Stable or unstable fracture Rarely involved neurologic comprimise

Criteria unstable

Loss of 50% of vert body height Angulation of thoracolumbar junct > 20 deg Mutiple adjacent column of spine Failure of 2/3 of column of spine

Chance fracture

Anterior column falls in tension (along w/ the middle and posterior columns) Three columns rupture in distraction (tension) Seldom assc w/ neurologic comprimise unless Unstable

Burst fracture

Compressive failure of vert body both anteriorly & posteriorly , w/ failure of both anterior & middle columns Axial loading applied to intravertebral disc results in increased nuclear pressure and hoop stresses in the annulus

Burst frx location Cervical burst fix Lumbar burst fix Thoracic burst fix Thoracolumbar burst fix

Classification : Stable frx - neurologically intact - poterior arch remains intact : pedicl widening implies post arch disruption - less than 50% anterior body height - compression fracture

Unstable frx - neurologic defisit - loss of 50% vertebral body height - fracture dislocation - thoracolumbar burst frx

Jefferson Fracture

Pediatric frx - frx proceeds thru open synchondroses, and may occur w/ minimal trauma/ - posterior synchondroses fuses at age 4 - anterior synchondroses fuses at age 7

Mechanism - original description in 1920 noted role of axial compression - may also be caused by hyperextension, causing a posterior arch fracture

Associated injuries - approx 1/3 of these fractures are associated with a axis fracture - approx 50% chance that some other C-spine injury is present - low rate of neurologic deficits is due to large breadth of C1 canal

Radiographs Odontoid view Lateral view Flexion and extension views CT scan

Dens Fracture

Odontoid fractures are the most common upper cervical spine fratures Remember rule of thirds cervical cord occupies a 1/3 of canal, dens occupies a 1/3 and the remaining 1/3 is empty Mechanism
Flexion loading Extension loading

Classification Type I Type 2 Dens frx Type 3

Associated Injury Atlas frx Transverse ligament rupture Pharangeal injury

Hangmans frx/Traumatic Spondylolisthesis of the Axis

Fix of pars interarticularis of C2 & disruption of C2-C3 junction Type of traumatic spondylolisthesis Hangmans frx Term Hangmans fracture is not accurate for the majority of cases, because mechanism of injury for clinically encountered frx often lacks large traction force present in judicial hangings

In cases in which there is neurologic injury, there will usually be significant horizontal translation w/ accompanying damage to the posterior longitudinal ligament w/ or w/o damage of the C2 C3 interspace

Mechanism of injury in adults

Judical lesion : hyperextension and distraction Hyperextension w/ vertical compression of posterior column, & translation of C2 and C3 Forceful extension of already extended neck is most commonly described mech of injury, but other causes include flexion of flexed neck & compression of an extended neck A blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles of C2 known as traumatic spondyloslishthesis of C2

SCIWORA Syndrome

Occurs may often in pediatric population Accounts for up to 2/3 of severe cervical injuries in children < 8 years of age Inherent elasticity in pediatric cervical spine can allow severe spinal cord injury to occur in absence of x-ray findings

Radiographs
Diagnosis of exclusion MRI may give a more anatomic diagnosis by showing hemorrage or edema of the spinal cord Pseudosubluxation : anterior displacement may be up to 4 mm

Clasification spinal cord injury

Complete Incomplete Anterior cord syndrome Central cord syndrome Brown sequad Cauda equina

Anatomy crossection spinal cord

Ascending Tract
Tracts of Goll and Burdach (fasc gracilis and cuneatus Dorsal and ventral spinocerebellar tract Lateral spinothalamic tract Spinal olivary tract Ventral spinothalamic tract Proprioception,vibration,dis crimination Proprioception, light touch Pain, temperature Tendon and muscle proprioception Deep tactile and pressure sensation uncrosssed uncrossed crossed crossed crossed

Descending Tract
Lateral corticospinal tract (pyramidal) Rubrospinal tract Lateral reticulospinal tract Reticulospinal tract Vestibulospinal tract Tectospinal tract Motor control uncrossed

Cerebellar reflexes Inhibits locomotor conytrol Facilittes locomotor control Postural control Eye and ear reflleces

crossed crossed uncrossed Uncrossed crossed

Complete / incomplete Spinal Cord Lession

Complete cord injury : there is complete loss of sensation and muscle function in the body below the level of the injury
An injury to the upper portion of the spinal cord in the neck can cause quadriplegia-paralysis of both arms and both legs. If the injury to the spinal cord occurs lower in the back it can cause paraplegia-paralysis of both legs only.

Incomplete lesion : there is some remaining function below the level of the injury. In most cases both sides of the body are affected equally.

Present when there is any distal sparing of motor or sensory function along with sparing of perirectal sensation

Diff dx of incomplete lesions

Central cord syndrome Brown sequard syndrome Anterior cord syndrome Posterior cord syndrome Isolated nerve root injury Cauda equina syndrome (w/ or w/o root escape) Conus medullaris injury

Anterior Cord Syndrome

Damage is primarily in the anterior 2/3 of cord and is related to vascular insuffiency There is sparing the posterior columns Syndrome is manisfested by complete motor paralysis (corticospinal func) and sensory anesthesi (spinothalamic func) Patient demonstrates greater motor loss in the legs than arms

Prognosis

anterior cord syndrome has the worst prognosis of all cord syndromes prognosis is good if recovery is evident & progressive during first 24 hours after 24 hrs, if no signs of sacral sensibility to pinprick or temp are present, prognosis for further functional recovery are poor; only 10 to 15% of patients demonstrate functional recovery;

Central Cord Syndrome

most common incomplete cord lesion frequently associated w/ extension injury to osteoarthritic spine (cervical spondylosis) in middle aged person who sustains hyperextension injury cord is injured in central gray matter, & results in proportionally greater loss of motor function to upper extremities than lower extremities w/ variable sensory sparing;

Anatomy: fibers responsible for lower extremity motor and sensory functions are located in the most peripheral part of the cord whereas fibers controlling the upper extremity and voluntary bowel and bladder function are more centrally located sacral tracts are positioned on the periphery of the cord & are usually spared from injury;

Mechanism of Injury: hyperextension injury central cord injury and hemorrhage occur with compression of adjacent white-matter tracts more peripheral positioning of lower extremity axons within the spinal cord tracts accounts for the injury pattern

damage to central portion of corticospinal and spinothalamic long tracts in white matter produces upper motor neuron spastic paralysis of trunk and lower extremity

Examination central cord syndrome is remarkable for more cord involvement in the upper extremities than in the lower extremities manifests w/ loss of distal upper extremity pain & temperature sensation and strength, w/ relative preservation of lower extremity strength & sensation

upper extremities: mixed upper and lower-motor-neuron lesion, w/ partial flaccid paralysis of upper extremities (indicative of involvement of lower motor neurons) prognosis is variable w/ poor hand function lower extremities: spastic paralysis of lower extremities (indicative of involvement of upper motor neurons) bladder and bowel function may also be lossed;

Brown Sequard Syndrome

type of incomplete cord syndrome injury to either side of spinal cord produces ipsilateral muscle paralysis (from corticospinal tract injury) and contralateral hypersthesia to pain and temperature (from spinothalamic injury)

syndrome results from hemitransection of spinal cord w/ unilateral damage to the spinothalamic & corticospinal tracts and resultant loss of ipsilateral motor & dorsal column function & of contralateral pain and temperature sensation often due to penetrating trauma or unilateral facet fracture or dislocation;

Prognosis: this syndrome has a good prognosis for recovery more than 90% of pts regain bladder & bowel control & ability to walk most patients will regain some strength in lower extremities and most will regain functional walking ability;;

Cauda Equina Syndrome

urinary retention is the most consistent finding in spinal cord injuries, the caudal equina may sustain considerable initial trauma in any potential cauda equina syndrome it is important to examine for saddle anesthesia, rectal tone, bulbocaverosus reflex, and sacral sparing;

Initial Evaluation

ABC
Airway, Breathing, Circulation and C-spine Back board with C-spine immobilization C-spine lateral x-ray

Management of neurogenic shock

Vascular hypotension with bradycardia Volume replacement, vasopressor Avoid pulmonary edema from fluid overload

Associated life-threatening injuries

Spinal Shock
Usually < 24 hrs Check for BulboCavernosus reflex!!!

Image Study

Plain x-ray
Vertebral height Focal kyphosis Level and type of injury

Above T9 spinal cord injury T10 to L1 spinal cord or root injury Below L2 root injury

Computed tomography

Canal compromise

Myelography, MRI

Neurologic Deficits1

Complete vs. Incomplete Injury?

Sacral sparing Incomplete injury

Frankel Classification
A. Absent motor and sensory function B. Sensation present, motor function absent C. Sensation present, motor function active but not useful (grade 2-3/5) D. Sensation present, motor function active and useful (grade 4/5) E. Normal motor and sensory function

ASIA Classification

Neurologic Deficits

High dose methylprednisolone

30 mg/kg bolus IV injection in 1st hour 5.4 mg/kg/hr continuous IV infusion since 2nd hour

Given in 3 hours after injury: maintain 24-hr therapy Given beyond 3 hours after injury: maintain 48-hr therapy Given beyond 8 hours after injury: no benefit!!!

Surgical Treatment
Indications: Neurological deficits (+) Neurological deficits (-)
Fracture-dislocations Burst fractures

Anterior vertebral height collapse >50% Focal kyphosis > 30 Canal compromise > 50% Sagittal index (SI) > 25

Surgical Treatment
Goals:

To create an optimal environment for neural recovery To ensure stabilization and early mobilization To minimize further neurological compromise from late deformity