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Muhammad Iqbal, Muhammad Iqbal, SpOT SpOT
Muhammad Iqbal, Muhammad Iqbal, SpOT SpOT
Muhammad Iqbal, Muhammad Iqbal, SpOT SpOT

Muhammad Iqbal,

Muhammad

Iqbal, SpOT

SpOT

 Medical problems:  initial immobilization  prolonged rehabilitation  significant readjustment in lifestyle  potential

Medical problems:

initial immobilization

prolonged rehabilitation

significant readjustment in lifestyle

potential complications in the chronic stages

Internal fixation: early mobilization & rehabilitation, more thorough decompression

Goals of SCI treatment: early aggressive tx & prevention of secondary injury

Primary Survey  A irway ( with C-spine protection )  B reathing and ventilation 

Primary Survey

Airway (with C-spine protection)

Breathing and ventilation

Circulation (with hemorrhage control)

Disability - neurologic status

Exposure and environment

Resuscitation

Other studies and monitors

Secondary survey

Injuries to the spine must be excluded after trauma:  55% involve the cervical spine 

Injuries to the spine must be excluded after trauma:

55% involve the cervical spine 15% involve the thoracic spine 15% involve the thoracolumbar region 15% involve the lumbosacral region

Primary injury Primary injury  Initial insult to to cord cord  Local Local deformation deformation

Primary injury

Primary

injury

Initial

Initial insult

insult toto

cord

cord

Local Local deformation deformation

Energy

Energy

transformation

transformation

Primary injury Primary injury  Initial insult to to cord cord  Local Local deformation deformation
Secondary Secondary injury injury  Biochemical Biochemical cascade cascade  Cellular Cellular Most Most acute acute

Secondary

Secondary injury

injury

Biochemical Biochemical

cascade

cascade

Cellular Cellular

Most

Most acute

acute therapies

therapies aimaim toto

processes

processes

limit secondary

limit

secondary injury

injury

cascade

cascade

Secondary Secondary injury injury  Biochemical Biochemical cascade cascade  Cellular Cellular Most Most acute acute
 1970’s: 1970’s: free free radicals radicals  1980’s: 1980’s: Ca, Ca, opiate opiate receptors receptors
 1970’s:
1970’s: free
free radicals
radicals
 1980’s:
1980’s: Ca,
Ca, opiate
opiate receptors
receptors
lipid
lipid peroxidation
peroxidation

1990/2000’s:

1990/2000’s: apoptosis

apoptosis

synthesis

synthesis

mechanisms

mechanisms

intracellular

intracellular protein

protein

glutaminergic

glutaminergic

In U.S. : 11,200  Death before hospital  Death in hospital  Survive : 4,200
In U.S. : 11,200  Death before hospital  Death in hospital  Survive : 4,200
In U.S. : 11,200  Death before hospital  Death in hospital  Survive : 4,200
In U.S. : 11,200  Death before hospital  Death in hospital  Survive : 4,200
In U.S. : 11,200  Death before hospital  Death in hospital  Survive : 4,200

In U.S. :

11,200

Death before hospital

Death in hospital

Survive

: 4,200

: 1,150

: 50%

In Dr. Sardjito hospital: 5-6 cases / month

Quadriplegia : 50% Paraplegia : 50% 80% < 40 y.o. ( 15-35 y.o.) in the hospital

Quadriplegia : 50%

Paraplegia

: 50%

  • 80% < 40 y.o.
    ( 15-35 y.o.)

  • in the hospital

10% paralysis increase during staying

  • Cerebral concussion : 20% with cervical fracture

CERVICAL VERTEBRAE : • More often • Especially C 5 - C6 • Wider mobility •
CERVICAL VERTEBRAE : • More often • Especially C 5 - C6 • Wider mobility •
CERVICAL VERTEBRAE : • More often • Especially C 5 - C6 • Wider mobility •
CERVICAL VERTEBRAE : • More often • Especially C 5 - C6 • Wider mobility •
CERVICAL VERTEBRAE : • More often • Especially C 5 - C6 • Wider mobility •

CERVICAL VERTEBRAE :

• More often

• Especially C 5 - C6

• Wider mobility

• Spinal canal 30% wider than spinal cord

THORACAL VERTEBRA

• Trauma Not so often

• Trauma • Complete paralysis

• Irreversible

VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi
VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi
VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi
VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi
VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi

VERTEBRAE LUMBAL :

• The most cases fracture T 12- L1

• Paraparese Paraplegi

NEUROLOGIC DISTURBANCES :

• Compression of the spinal cord

• Disruption of the vascularization

VERTEBRAE LUMBAL : • The most cases fracture  T 12- L1 • Paraparese  Paraplegi

Death neuron in 4 hours

Dysfunction of the spinal cord

 Based on key muscle strength & key sensory points  Useful for following improvement or

Based on key muscle strength & key sensory points Useful for following improvement or deterioration

 Based on key muscle strength & key sensory points  Useful for following improvement or

PREHOSPITAL

PREHOSPITAL CARE

CARE

1. ABC evaluation, B6 evaluation

  • 2. Vital sign

  • 3. Seeking for painful, consciousness evaluation

  • 4. Cervical palpation – neurologic evaluation

    • 5. Examination the others trauma

    • 6. Splinting stabilization

    • 7. Medication

  • SPINAL CORD INJURY

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

WEAK

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
  • SPASM

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

BLADDER

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

Bowel

PRESSURE

Distension

SORES

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

RESPIRATION

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
  • DYSFUNCTION

CONTRACTURES

RESPIRATORY

INFECTION

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

PSYCOLOGICAL

FACTORS

ACUTE

  • INFECTION

URINARY

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

PROTEIN LOSS AND ANAEMIA

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

LOSS OF

APPETITE

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
DEATH
DEATH

PYELONEPHRITIS

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

POOR RESISTANCE TO INFECTION

SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION
SPINAL CORD INJURY WEAK SPASM BLADDER Bowel PRESSURE Distension SORES RESPIRATION DYSFUNCTION CONTRACTURES RESPIRATORY INFECTION

CACHEXIA

SUSPECTED CERVICAL

SUSPECTED

CERVICAL FRACTURE

FRACTURE

Keep unmoving of the head

• Apply cervical collar

Fixing sand-bag pillow beside the head

• Traction: Glisson, Crutch field traction

Lifting the patient in a unite:

4 persons

VERTEBRAE FRACTURE

VERTEBRAE

FRACTURE WITH

WITH PARALYSIS

PARALYSIS

SPINAL SHOCK

SPINAL

SHOCK

Paralysis + sensibility disturbances

• Areflexia

Micturation and defication disturbances

• Unsweating

No perianal sensation

• No Bulbocavernous reflex

Lasting < 24 hours

INCOMPLETE LESION

INCOMPLETE

LESION

Paralysis (+) / (-)

• Perianal sensation (+)

Moving voluntary finger of the foot (+)

• Anal contraction voluntary (+)

Bulbocavernous reflex (+)

INCOMPLETE LESION INCOMPLETE LESION • Paralysis (+) / (-) • Perianal sensation (+) • Moving voluntary

After recovery of the spinal shock

COMPLETE LESION

COMPLETE

LESION

Paralysis

: Total

• Sensibility (-)

Bulbocavernous reflex (+)

• Plantar moving big-toe – stimulation: slowly

Priapismus

COMPLETE LESION COMPLETE LESION • Paralysis : Total • Sensibility (-) • Bulbocavernous reflex (+) •

After recovery of the spinal shock

Fracture C3C3 -- C4C4 ::

Fracture

Abdominal

respiratory

n. intercostal

Lesion respiratory

distress death

Fracture C7C7 -- T1:

Fracture

T1:

Horner syndrome

Horner

syndrome

Ptosis

Enopthalmus

Anhidrosis

Miosis

MANAGEMENT

MANAGEMENT

Bed rest - spinal board

• Collar brace

Infus maintenance

• Fasting

Catheter

• Gastric distension evaluation – gastric cube

• Dexamethason / metil prednisolon inj., if < 8 hours

• Vital sign & neurologic Evaluation

• If : spinal shock: T, P, HR

  • Limitation fluid management

  • Sympatomimetic

- Two column concept: - Anterior – posterior column - Disruption posterior column: unstable - Three
  • - Two column concept:

    • - Anterior – posterior column

    • - Disruption posterior column: unstable

  • - Three column concept:

    • - Anterior-middle-posterior column

    • - Disruption of two column : instability

  • - Neurologic dysfunction: instability

  • TREATMENT

    TREATMENT

    1. Operation : Unstable

    • Neurologic deficit

    • Kyphosis > 30 o (thoraco-lumbal),

    cervical > 11 o

    Translation vertebrae / Dislocation

    • 2 columns fracture

    • Vertebrae body height collapse > 50%

    • Protrusion to spinal canal > 30%

    TREATMENT TREATMENT 1. Operation : Unstable • Neurologic deficit • Kyphosis > 30 (thoraco-lumbal), cervical >

    • Release spinal cord compression

    • Stabilization : Plate + Screw + Wire, Nail + Wire

    Continuity of the Ligamentum Flavum
    Continuity of the Ligamentum Flavum

    Continuity of

    Continuity of the Ligamentum Flavum

    the

    Ligamentum

    Flavum

    Anterior Alone vs. Combined A/P
    Anterior Alone vs. Combined A/P
    Anterior Alone vs. Combined A/P

    Anterior

    Alone vs.

    Combined

    A/P

    TREATMENT

    TREATMENT

    2. Conservative

    • Bed rest

    • Traction

    • Collar brace

    • Minerva cast (cervical)

    • Body jacket brace / cast (thoraco-lumbal)

    • Hemi-spica cast (> L3)

    IfIf must

    must bebe operated,

    operated,

    but

    but not

    not toto bebe operated

    operated ::

    • Paralysis after few years

    • Painful

    • Hyper kyphosis

    I