Spinal Injury

&
Spinal Cord
Injury

GEB - 2017
• ANATOMI
• PASIEN DENGAN CEDERA SPINAL
• SYOK NEUROGENIK
• SYOK SPINAL
• CEDERA SPINAL KOMPLIT VS INKOMPLIT
• DIMANA
• KOMPLIKASI
ANATOMI
 Spinal
Cord
Protection
Bones- vertebral
column
7 Cervical
12 Thoracic
5- Lumbar
5- Sacral

Discs-
between
vertebra
Spinal Cord Protection

• Internal and external

ligaments
• Dura
• Meninges
• CSF in subarachnoid
space allow for
movement within
spinal canal
Epidemiologi
• 50 % kasus cedera spinal adalah tipe
komplit
• 50-60 % kasus cedera spinal terjadi pada
daerah cervical
• Immediate mortality pada kasus cedera
spinal tipe komplit adalah 50 %
• Terjadi sebagian besar pada C5, C6, C7, Th
12, L1
DEFINISI SCI
• Cedera pada kolumna vertebralis dan/atau
korda spinalis
– Cedera Kolumna Vertebralis
– Cedera Korda Spinalis
– Campuran
Cedera Kolumna Vertebralis
• Cedera Tulang
– fraktur vertebra
– Subluksasi vertebra
• Cedera Non-Tulang
– Ligamen
• Sprain / over streching
• Ruptur / Robek
– Otot
• Sprain / over streching
• Ruptur / Robek
Cedera Korda Spinalis
• Mekanisme cedera
– Cutting (terpotong oleh segmen patahan
tulang yang tajam)
– Kompresi
– Stretching (akan lebih berat pada pasien
dengan tethered cord)
Mechanism of Injury
Flexion
Hyperextension
Compression
Flexion /Rotation
Classifications of SCI
Mechanism of Injury

Flexion (hyperflexion)
 Most common because of
natural protection position.
 Generally cause neck to be
unstable because stretching
of ligaments
SCI- Hyperflexion
Classifications of SCI
Mechanism of Injury

Hyperextention
 Caused by chin hitting a
surface area, such as
dashboard or bathtub
 Usually causes central cord
syndrome symptoms
Classifications of SCI
Mechanism of Injury

Compression
 Caused by force from above,
as hit on head
 Or from below as landing on
butt
 Usually affects the lumbar
region
Classifications of SCI
Mechanism of Injury

Flexion/Roatation
 Most unstable
 Results in tearing of
ligamentous structures that
normally stabilize the spine
 Usually results in serious
neurologic deficits
Pasien dengan kecurigaan
cedera spinal
 Pasien tidak sadar (termasuk curiga intoksikasi)
 Defisit Neurologis
 Nyeri / Nyeri tekan pada posterior midline
 Cedera Multiple (multitrauma)
Syok Neurogenik
Syok Neurogenik
 Akibat hilangnya tonus vasomotor
simpatik
 Mengakibatkan rangsang dominanoleh
parasympatis
 Kehilangan rangsang simpatik
menyebabkan peripheral pooling
(vasodilatasi perifer) dan menurunnya
cardiac output
 Hipotensi dan bradikardi
 Hipotensi Orthostatic dan gangguan
kontrol suhu (poikilothermic)
 Syok Neurogenik
• Gangguan fungsi autonom spinalis setinggi level
cedera
– Akibat cedera cervikal atau thorakal atas
• Gejala
– Flaccid paralysis distal dari level cedera
– Kehilangan fungsi otonomik
• Hipotensi
• bradikardi
• Vasodilatasi
• Kehilangan kontrol saluran kemih dan pencernaan
• Kehilangan kontrol sistem termoregulasi
Perbandingan antara syok neurogenik
dan syok hipovolemik

Neurogenic Hypovolemic
Etiologi Kehilangan fungsi Kehilangan volume
simpatis darah
Tekanan Hipotensi Hipotension
Darah
Nadi Bradikardi Takikardia

Temperatur hangat dingin

Produksi Normal berkurang

urin 21
SYOK SPINAL
Syok Spinal dan Syok Neurogenik
• Syok Spinal
– Kehilangan seluruh atau sebagian
reflek-reflek motorik and kehilangan
fungsi sensoris dibawah level cedera
– Motor loss - flaccid paralysis dibawah
level cedera
– Sensory loss - loss touch, pressure,
temperature pain and proprioception
perception dibawah level cedera
– Dapat berlangsung berhari-hari hingga
bulan
Perbedaan antara syok spinal dan syok
neurologis
• Syok spinal didominasi oleh hilangnya /
menurunnya reflek-reflek (flaccid paralysis)
• Syok neurogenik didominasi oleh kelainan
fungsi otonom biasanya terjadi hipotensi dan
bradikardia karena hilangya tonus atau
rangsang simpatis
Bagaimana cara mengetahui bahwa syok spinal
sudah berakhir ?

 Clonus merupakan tanda

pertama
 Muncul Hiperrefleks
 Dilakukan dengan cara
melakukan fleksi dari lutut
disertai dengan dorsofleksi
cepat dari kaki
 Positif bila muncul Rhythmic
oscillations pada kaki
• Syok spinal
– Refleks Bulbocavernosus (-)
– Clonus (-)
DIMANA LESI NYA ????

PEMERIKSAAN FISIK
 Pasien sadar atau
tidak sadar?
• Apa perbedaannya?
– Sadar
• Dapat dilakukan tanya jawab
• Nyeri / nyeri tekan
OW!
• Pemeriksaan motorik /
sensorik

– Tidak sadar
• Tidak bisa tanya jawab
• Tidak dapat menentukan nyeri tekan
• Tidak dapat dilakukan
pemeriksaan motorik ------
dan sensorik
Motorik
• a) Gerakan kedua Lengan
• b) Gerakan Kedua Tangan
• c) Gerakkan Kedua Kaki
• d) Gerakkan Jempol Kaki
Pemeriksaan Neurologis
landmark dermatom

– Nipple line –T4

– Xiphoid process-
T7
– Umbilicus –T10
– Inguinal region –
T12,L1
– Perineum and peri-
anal region
(S2,S3&S4)
 “Tidak sadar”

“Tidak dapat diperiksa”

Pemeriksaan umum
• Inspeksi dan palpasi
– Occiput to Coccyx
– Kemerahan dan bengkak jaringan lunak
– Titik nyeri tekan (pasien sadar)
– Gap or Step-off
– Spasme
Pemeriksaan umum
• Kepala dan telinga
• Palpasi prosesus Spinous dan ligamen
interspinous
• Fleksi pada siku bila terjadi hilangnya
rangsang motorik dibawah bisep / ekstensi
siku bila terjadi paralisis diatas bisep
• Ereksi penis dan inkontinensia sistem
pencernaan dan urin
• Flaccid Paralysis – Quadriplegia
Tindakan Awal di tempat kejadian
1. Imobilisasi tulang belakang sebelum dan selama proses
transportasi / pemindahan untuk mencegah gerakan aktif
maupun pasif dari tulang belakang
2. Menjaga tekanan darah
– Syok neurogenic  kehilangan tonus simpatis
– Cegah over rehidrasi cairan
– Pilihan utama adalah penggunaan dopamin
3. Menjaga oksigenasi
– adequat FIO2 and adequat ventilasi
4. Pemeriksaan motorik singkat
– a) Gerakan kedua Lengan
– b) Gerakan Kedua Tangan
– c) Gerakkan Kedua Kaki
– d) Gerakkan Jempol Kaki
 Pemeriksaan Radiologis
• Apa saja indikasi pemeriksaan x-ray pada
cedera spinalis ?

 NEXUS -The National Emergency X- Radiograph

Utilization Study
– Prospective study to validate a rule for the decision to obtain
cervical spine x- ray in trauma patients
– Hoffman, N Engl J Med 2000; 343:94-99
 Canadian C-Spine rules
– Prospective study whereby patients were evaluated for 20
standardized clinical findings as a basis for formulating a
decision as to the need for subsequent cervical spine
radiography
– Stiell I. JAMA. 2001; 286:1841-1846
 NEXUS

• NEXUS Criteria:
1. Tidak adanya nyeri tekan pada sisi tulang
belakng (posterior midline)
2. Tidak adanya defisit neurologis
3. Sadar (skor GCS = 15)
4. Tidak ada kecurigaan penggunaan narkoba dan
alkohol sebelumnya
5. Tidak ada nyeri atau cedera disekitar tulang
belakang
 NEXUS

• Pasien yang memenuhi keseluruhan kriteria

termasuk dalam kategori resiko rendah
mengalami cedera spinalis
 Tidak perlu X-ray C-spine

• Pasien yang mengalami salah satu dari

kriteria tersebut harus menjalani
pemeriksaan radiologis
 ( AP, lateral and open mouth views)
The Canadian C-spine Rule for alert and stable trauma patients where cervical
spine injury is a concern.

• Apakah pasien dalam kategori beresiko besar sehingga

perlu pemeriksaan radiologi?
– Umur > 65 tahun
– Mekanisme cedera yang berbahaya
– Paresthesia pada anggota gerak

NO
Apakah aman bila dilakukan pemeriksaan YES
dengan provokasi gerakan ?
• Simple rear-end MVC, or
• posisi duduk NO
• ambulatory, or
Radiography
• nyeri leher onset lambat, or
• Tidak adanya nyeri tekan pada sisi tengah C-
spine
YES
Dapat melakukan rotasi leher tanpa nyeri? TIDAK MAMPU
• 45 derajat ke kiri dan kanan
MAMPU
No Radiography
 National Emergency X
Radiography Utilization Study
(NEXUS)

&
The Canadian C-spine rule

Both have:
• Excellent negative predictive value for
excluding patients identified as low risk
Clearance of Cervical Spine Injury in
Conscious, Symptomatic Patients

1. Radiological evaluation of the cervical spine is

indicated for all patients who do not meet the
criteria for clinical clearance as described
above

2. Imaging studies should be technically adequate

and interpreted by experienced clinicians
Pemeriksaan Radiologis pada
Cervical Spine
– Plain films
• AP, lateral and open mouth view
– Bila diperlukan: Oblique and Swimmer’s

– CT
• Baik pada kasus fraktur tertutup

– MRI
• Baik untuk evaluasi spinal cord, jaringan lunak dan
cedera ligamen

– Flexion-Extension Plain Films

• Untuk menentukan stabilitas
 Tatalaksana Cedera Spinal

• Tujuan Utama
– Mencegah cedera sekunder

• Immobilisasi tulang belakang dimulai sejak ABC

– Treat the spine as a long bone
• Secure joint above and below
– Caution with “partial” spine splinting
Tindakan Awal
1. Imobilisasi tulang belakang sebelum dan selama proses
transportasi / pemindahan untuk mencegah gerakan aktif
maupun pasif dari tulang belakang
2. Menjaga tekanan darah
– Syok neurogenic  kehilangan tonus simpatis
– Cegah over rehidrasi cairan
– Pilihan utama adalah penggunaan dopamin
3. Menjaga oksigenasi
– adequat FIO2 and adequat ventilasi
4. Pemeriksaan motorik singkat
– a) Gerakan kedua Lengan
– b) Gerakan Kedua Tangan
– c) Gerakkan Kedua Kaki
– d) Gerakkan Jempol Kaki
 Tindakan Awal: Stabilisasi
Cervical Spine
 Tujuan UTAMA:
 Menjaga ALIGNMENT ANTARA
KEPALA DAN LEHER agar
tetap sejajar dengan long axis
tubuh
 DILAKUKAN MULAI DARI
TEMPAT KEJADIAN,
TRANSPORTASI, DAN DI
RUMAH SAKIT
 Menunjuk satu orang untuk
bertanggung jawab menjaga
immobilisasi kepala leher
On-Field Evaluation
On-Field Evaluation
 On-Field Evaluation
 Removing the Athlete from the
Field:
 Using a Spine Board: Supine
athlete
 Continue to stabilize head and
neck throughout the roll and on
the spine board
 Use chin straps and foam blocks
to secure the head on the board
 Secure the limbs with straps
 Distribute help personnel and lift
together
 On-Field Evaluation
 Initial Action: Primary Survey / LOC
 Determine level of consciousness:
 “Can you hear me”
 Response to painful stimulus
 Determine ABCs:
 Clear the airway and assess breathing
 Remove mouthpiece
 Check Circulation
 Inspect ears and nose:
 CSF
 Secondary Survey:
 Signs of trauma (fracture, dislocations, bleeding)
 Management of SCI

• Spinal motion restriction: immobilization devices

• ABCs
– Tingkatkan FiO2
– Jaga jalan nafas dan pernafasan disertai stabilisasi C-
Spine
– Indikasi untuk intubasi :
• Gagal Nafas Akut
• GCS <9
• Peningkatan RR disertai hypoxia
• PCO2 > 50
• VC < 10 mL/kg
– IV Access & fluids titrated to BP ~ 90-100 mmHg
 Management of SCI

• Look for other injuries: “Life over Limb”

• Transport to appropriate SCI center once
stabilized
• Consider high dose methylprednisolone
– Controversial as recent evidence questions benefit
– Must be started < 8 hours of injury
– Do not use for penetrating trauma
– 30 mg/kg bolus over 15 minute
– After bolus: infusion 5.4mg/kg IV for 23 hours
 Prinsip Tatalaksana
Cedera Spinal
• Spinal alignment
– deformity/subluxation/dislocation reduction

• Spinal column stability

– unstable  stabilization

• Neurological status
– neurological deficit  decompression
KOMPLIKASI
Masalah Keperawatan

• 1.Kesulitan Mobilisasi
• 2.Gangguan Pertukaran Gas
• 3. Gangguan integritas kulit
• 4. Konstipasi
• 5. Gangguan sistem kemih
• 6. Resiko autonomic dysreflexia
• 7. Gangguan lain (Sex, kejiwaan, dll)
1. Kesulitan Mobilisasi
• Log roll sebagai single unit; minta bantuan
untuk menjaga alignment
• Perawatan traksi, collars, splints, braces,
• Flaccid paralysis - gunakan high top tennis
shoes atau splints untuk mencegah
kontraktur. Lepas tiap 2 jam untuk latihan
gerak (menjaga ROM aktif)
1. Impaired Physical Mobility
• Spastic Paralysis
– Prevent spasms by avoiding; sudden
movements or jarring of the bed; internal
stimulus (full bladder/skin breakdown; use of
footboard; staying in one position too long;
fatigue
– Treat spasms by decreasing causes; hot or cold
packs; passive stretching; antispasmodic
medications
• Assess skin break down thrombophlebitis;
remove TED hose at least every shift
1. Impaired Physical Mobility
• Prevent/treat orthostatic hypotension
– Abdominal binder, calf compressors, TED
hose when individual gets up
– Assess BP, especially when rising

– Teach use of transfer board

– Assist Physical Therapy with tilt table as
individual gradually gets use to being in an
upright position
2. Impaired Gas Exchange
• Phrenic nerve (C3-5) controls the diaphragm
bilaterally. If nerve is nonfunctioning then
individual is ventilator dependent.
• Thoracic nerves control the intercostals
muscles for breathing and abdominal muscles
aide in breathing and coughing
2. Impaired Gas Exchange
• Respiratory rate, rhythm,
depth, breath sounds,
respiratory effort, ABG’s, O2
saturation

• Signs of impending extension

of SCI up cord to phrenic nerve
level (C3-5)
• Need for ventilatory assistance
tracheotomy, ventilator

• Quad cough (assistive cough)

as needed
3. Impaired Skin Integrity
• Change position frequently
• Protection from extremes in temperature
• Inspect skin at least 2x/day especially over boney
prominences
• Avoid shearing and friction to soft tissue with transfers
• Removal of TED hose every 8 hours
• Nutritional status
4. Constipation

• Bowels rely more on bulk than on nerves

• Stimulate bowels at the same time each day.
Best after a meal when normal peristalsis
occurs
• Individual may progress from Dulcolax
suppository to glycerin then to gloved finger
for digital stimulation
• Assess bowel sounds prior to giving food for
the first time– paralytic ileus!
5. Impaired Urinary
Elimination
 Flaccid bladder (lower motor neuron lesion)
No reflex from S2,3,4
Automatic empting of bladder
Urine fills the bladder and dribbles out
Need Foley or freq intermittent self
catheterization

 Spastic bladder (upper motor neuron lesion)

Reflex arc but no connection to or from brain
Reflex fires at will
Bladder training- trigger points to stimulate empting;
self catheterization
5. Impaired Urinary Elimination
• Use bladder scan to see amount of urine in
bladder
• Goal- residual <100ml/20% bladder capacity
• Some individuals may need suprapubic
catheter
• Assess effectiveness of medication
– Urecholine to stimulate bladder contraction
– Urinary antiseptic
6. Risk for Autonomic
Dysreflexia
• SCI above T6
• Results in loss of normal compensatory
mechanisms when sympathetic nervous
system is stimulated
• Life threatening- if goes unchecked BP can
result in cerebral hemorrhage

• Vasodilatation symptoms above SCI

• Vasoconstriction symptoms below SCI
• The cause of SNS stimulation
6. Risk for Autonomic
Dysreflexia
• Elevate head of bed- causes orthostatic
hypotension
• Identify cause/alleviate- if full bladder- cath;
if skin- remove pressure, if full bowel- empty,
etc
• Remove support hose/abdominal binder
• Monitor blood pressure- can get > 300 S
• Give PRN medication to lower BP
• If above not effective– call physician
7. Ineffective Coping/
Grief and Depression
• Assess thoughts on ‘quality of life’; body
image; role changes
• Physical and psychological support
• Most common SCI is 15-30 yeas old and
generally a risk taker– this greatly affects
their perception of life and rehabilitation
7. Ineffective Coping/sexuality
Male Female
• UMN lesion • hormones more than
– reflexogenic (S2,3,4) nerves regarding fertility.
erections • C-section because of
• LMN lesion chance for autonomic
– psychogenic erections dysreflexia during labor.
(psychological
stimulation) • Lack of
sensation/movement
affects sexual performance
• Ejaculation/fertility may
be affected
7. Ineffective
Coping/sexuality
• Assess readiness/knowledge/your ability
• Use proper terminology
• Suggestions:
– empty bladder before sex
– withhold fluids and antispasmodics
– certain positions may increase spasms
– explore new erogenous zones
– penile implants
• Refer to specially trained counselor
Home Care
• Assess psychological, physiological resources
• need for rehabilitation (in-house or out
patient)
• need for community resources

• Home assessment
Jefferson Fracture
• Burst fracture of C1 ring

• Unstable fracture

• Increased lateral ADI on

lateral film if ruptured
transverse ligament and
displacement of C1 lateral
masses on open mouth view

• Need CT scan
Burst Fracture

• Fracture of C3-C7 from

axial loading

• Spinal cord injury is

common from posterior
displacement of fragments
into the spinal canal

• Unstable
Clay Shoveler’s Fracture

• Flexion fracture of
spinous process

• C7>C6>T1

• Stable fracture
Flexion Teardrop Fracture

• Flexion injury causing a

fracture of the
anteroinferior portion of
the vertebral body

• Unstable because
usually associated with
posterior ligamentous
injury
Bilateral Facet Dislocation

• Flexion injury
• Subluxation of dislocated
vertebra of greater than
½ the AP diameter of the
vertebral body below it
• High incidence of spinal
cord injury
• Extremely unstable
Hangman’s Fracture

• Extension injury

• Bilateral fractures of
C2 pedicles
(white arrow)

• Anterior dislocation of
C2 vertebral body
(red arrow)

• Unstable
 Odontoid Fractures

• Complex mechanism of injury

• Generally unstable
• Type 1 fracture through the tip
– Rare
• Type 2 fracture through the base
– Most common
• Type 3 fracture through the base and body
of axis
– Best prognosis
Odontoid Fracture Type II
Odontoid Fracture Type III
 THANK YOU
FOR YOUR ATTENTION
SYOK SPINAL VS SYOK
NEUROLOGIS
 Syok Neurogenik
• Gangguan fungsi autonom spinalis setinggi level
cedera
– Akibat cedera cervikal atau thorakal atas
• Gejala
– Flaccid paralysis distal dari level cedera
– Kehilangan fungsi otonomik
• Hipotensi
• bradikardi
• Vasodilatasi
• Kehilangan kontrol saluran kemih dan pencernaan
• Kehilangan kontrol sistem termoregulasi
Perbandingan antara syok neurogenik
dan syok hipovolemik

Neurogenic Hypovolemic
Etiologi Kehilangan fungsi Kehilangan volume
simpatis darah
Tekanan Hipotensi Hipotension
Darah
Nadi Bradikardi Takikardia

Temperatur hangat dingin

Produksi Normal berkurang

urin 85
Terminologi
• Level neurologis
– Segmen paling bawah dengan fungsi motorik dan
sensorik normal dikedua sisi
• Level skeletal
– Level kerusakan vertebra berdasarkan radiologi
• Derajat keparahan cedera
– Komplit Kehilangan fungsi motorik dan sensorik
pada segmen sacral terbawah
– Inkomplit Fungsi sensorik dan motorik dibawah
level cedera masih berfungsi namun tidak total
What is the difference between
spinal shock and neurogenic
shock?
• Spinal shock is mainly a loss of reflexes
(flaccid paralysis)
• Neurogenic shock is mainly hypotension and
bradycardia due to loss of sympathetic tone
Spinal and Neurogenic Shock
• Spinal Shock
– Decreased reflexes and loss of
sensation below the level of injury
– Motor loss- flaccid paralysis below level
injury
– Sensory loss- loss touch, pressure,
temperature pain and proprioception
perception below injury
– Lasts days to months
Spinal and Neurogenic Shock

Neurogenic shock
 Due to loss of vasomotor tone
 SNS loss results in parasympathetic
dominance with vasomotor failure
 Loss of SNS innervation causes
peripheral pooling and decreased
cardiac output
 Hypotension and Bradycardia
 Orthostatic hypotension and poor
temperature control (poikilothermic)
How do you know spinal shock is over?

• Clonus is one of the first

signs
• Hyperreflexia of foot
• Test by flexing leg at knee
& quickly dorsiflex the
foot
• Rhythmic oscillations of
foot against hand
• clonus
 Cedera spinal (Komplit VS inkomplit)
 Sakral sparing
 Pasien Sadar
 Kontrol sphincter ani secara sadar

 Fleksi ibu jari

 Sensoris Perianal

 Pasien Tidak sadar

 Reflek Anal – Cutaneus

 Tonus spinchter ani

Incomplete cord injury
• Sindroma Anterior cord
• Sindroma Brown-Sequard
• Sindroma Central cord
Sindroma Anterior cord

• Kehilangan fungsi
motorik, suhu dan
nyeri

• Fungsi propiosepsis
dan sensoris
persendian masih
terpreservasi
Sindroma Brown-Sequard

• Kehilangan fungsi
motorik dan
propriosepsis
ipsilateral

• Kehilangan fungsi
perasa nyeri dan
suhu di sisi
kontralateral
Sindroma Central cord

• Kelemahan :
– atas > bawah

• Kehilangan fungsi
sensoris yang
bervariasi

• Sacral sparing