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Epidemiology
Department of Surgery
Faculty of Medicine
Mulawarman University
Etiology
By Vitale et al
Motor vehicle accidents - 56%
Accidental falls - 14%
Firearm injuries - 9%
Sports injuries - 7%
Department of Surgery
Faculty of Medicine
Mulawarman University
Department of Surgery
Faculty of Medicine
Mulawarman University
Department of Surgery
Faculty of Medicine
Mulawarman University
Department of Surgery
Faculty of Medicine
Mulawarman University
Department of Surgery
Faculty of Medicine
Mulawarman University
Motoric Pathways
Department of Surgery
Faculty of Medicine
Mulawarman University
Sensoric Pathways
The dorsal columns are ascending
sensory tracts that transmit light
touch, proprioception, and
vibration information to the
sensory cortex.
The lateral spinothalamic tracts
transmit pain and temperature
sensation.
The anterior spinothalamic tract
transmits light touch.
Department of Surgery
Faculty of Medicine
Mulawarman University
Autonomic
Pathways
Autonomic function traverses
within the anterior interomedial
tract
Sympathetic nervous system
fibers exit the spinal cord
between C7 and L1
Parasympathetic system
pathways exit between S2 and
S4
Department of Surgery
Faculty of Medicine
Mulawarman University
Pathophysiology
Spinal cord injury can be sustained through different
mechanisms, with the following 3 common abnormalities
leading to tissue damage:
Destruction from direct trauma
Compression by bone fragments, hematoma, or disk
material
Ischemia from damage or impingement on the spinal
arteries
Might result in shock state (Neurogenic/spinal)
emergency!
Department of Surgery
Faculty of Medicine
Mulawarman University
Pathophysiology
Complete Spinal Cord Syndrome : complete loss of motor
and sensory function below the level of the traumatic
lesion
Incomplete cord syndromes have variable neurologic
findings with partial loss of sensory and/or motor function
below the level of injury; these include the anterior cord
syndrome, theBrown-Squard syndrome, and the central
cord syndrome
Other cord syndrome : conus medullaris syndrome, cauda
equina syndrome, and spinal cord concussion
Department of Surgery
Faculty of Medicine
Mulawarman University
History & PE
Department of Surgery
Faculty of Medicine
Mulawarman University
PE
Department of Surgery
Faculty of Medicine
Mulawarman University
PE
Department of Surgery
Faculty of Medicine
Mulawarman University
PE
Department of Surgery
Faculty of Medicine
Mulawarman University
PE
Clinical "pearls" useful in distinguishing hemorrhagic
shock from neurogenic shock:
1. Neurogenic shock ONLY in acute spinal cord injury
above T6; hypotension and/or shock with acute spinal
cord injury at or below T6 is caused by hemorrhage
2. Hypotension with a spinal fracture alone, without any
neurologic deficit or apparent spinal cord injury, is
invariably due to hemorrhage
Department of Surgery
Faculty of Medicine
Mulawarman University
PE
History & PE
Department of Surgery
Faculty of Medicine
Mulawarman University
ASIA Impairment
Scale
Department of Surgery
Faculty of Medicine
Mulawarman University
ASIA Impairment
Scale
Department of Surgery
Faculty of Medicine
Mulawarman University
Workup
Department of Surgery
Faculty of Medicine
Mulawarman University
Workup
Diagnostic imaging
Standard radiographs of the affected region of the spine
radiography is insensitive to small fractures of the
vertebra
standard 3 views of the cervical spine are recommended
in patients with suspected spinal cord injury (SCI):
anteroposterior (AP), lateral, and odontoid
must include the C7-T1 junction to be considered
adequate
Department of Surgery
Faculty of Medicine
Mulawarman University
Workup
CT scanning with sagital and coronal reformatting is more
sensitive than plain radiography for the detection of
spinal fractures
Perform CT scanning in the following situations:
When plain radiography is inadequate or fails to
visualize
Convenience and speed: CT scan of the head CT of
the cervical spine at the same time
To provide further evaluation when radiography depicts
suspicious and/or indeterminate abnormalities
When radiography depicts fracture or displacement
provides better visualization of the extent and
displacement of the fracture
Department of Surgery
Faculty of Medicine
Mulawarman University
Workup
Department of Surgery
Faculty of Medicine
Mulawarman University
Management
Department of Surgery
Faculty of Medicine
Mulawarman University
Management
Circulation
Once occult sources of hemorrhage have been excluded,
initial treatment of neurogenic shock focuses on fluid
resuscitation.
Judicious fluid replacement with isotonic crystalloid
solution to a maximum of 2 L is the initial treatment of
choice.
Overzealous crystalloid administration may cause
pulmonary edema, because these patients are at risk for
the acute respiratory distress syndrome (ARDS) check
routinely for ronchi
Department of Surgery
Faculty of Medicine
Mulawarman University
Management
Department of Surgery
Faculty of Medicine
Mulawarman University
Management
Heart rate should be 60-100 bpm (in normal sinus
rhythm)
Hemodynamically significant bradycardia may be
treated with atropine
Urine output should be more than 30 mL/h Foley
catheter to monitor urine output and to decompress the
neurogenic bladder
Rarely, inotropic support with dopamine or
norepinephrine is required; this should be reserved for
patients who have decreased urinary output despite
adequate fluid resuscitation; usually, low doses of
dopamine in the 2- to 5-mcg/kg/min range are sufficient
Department of Surgery
Faculty of Medicine
Mulawarman University
Prevent hypothermia
Management
Department of Surgery
Faculty of Medicine
Mulawarman University
Medication
Department of Surgery
Faculty of Medicine
Mulawarman University
Medication
Department of Surgery
Faculty of Medicine
Mulawarman University
Medication
Analgetics
GABA analogs have been shown to be effective in treating
neuropathic pain in spinal cord injuries More patients
taking pregabalin (150-600 mg/d) showed 30% and 50%
reductions in pain than those taking placebo
Department of Surgery
Faculty of Medicine
Mulawarman University
Complications
Neurologic deterioration
often increases during the hours to days following
acute injury, despite optimal treatment
Pressure sores
Careful and frequent turning of the patient is required
to prevent pressure sores
Denervated skin is particularly prone to this
complication
Remove belts and objects from back pockets, s.a. keys
and wallets
Aspiration and pulmonary complications
Nasogastric decompression of the stomach is
mandatory
Department of Surgery
Faculty of Medicine
Mulawarman University
Department of Surgery
Faculty of Medicine
Mulawarman University