PARAPLEGIA EC COMPLETE SPINAL

CORD INJURY EC BURST FRACTURE

VERTEBRA LUMBAL 1 AND
COMPRESSION FRACTURE
VERTEBRA THORACAL 12 AND
DECUBITUS ULCER STAGE III
Moh. Dimas Ismail

Advisor:
dr. Zuwanda Then
Dr. Wendelin
Supervisor:
Dr. dr. Karya Triko Biakto, Sp. OT (K) Spine
PATIENT IDENTITY

 Patient Name : Mr. A

 Gender : Male
 Age : 41 y.o
 Job : Farmer
 Hospital : RSWS
 RM : 673278
 Date of Admittance : 16th September 2014
HISTORY TAKING
 Chief Complaint : Unable to move both legs

 Suffered since 3 months before admitted to the hospital due to

fell of from the tree about 5 metres tall. Soon after the
incidence patient can’t move and feel numbness on both of
their legs. Patient cant control his bladder and bowel function.
Patient also complaint about his erection problem. There’s
history of prior treatment in Poso Hospital. There’s history of
bone setter but there’s no improvement.

 Mechanism of Trauma :
 Patient fell of from the tree with the back of patient landed
first to the ground.
PHYSICAL EXAMINATION
 Status Present
 Well Nourished/Composmentis
 Vital Sign
 Blood Pressure : 120/70 mmHg
 Pulse : 80/ minute
 Respiratory Rate: 20/ minute
 Temperature : 36,7 oC
PHYSICAL EXAMINATION
 Head region : anemia (+), icteric (-), cyanosis(-)
 Neck region : thyroid enlargement (-), nodule (-),
tenderness (-)
 Thorax region : breath sounds : vesicular
additional sounds : Rh: -/-, Wh: -/-
 Heart region : heart sounds: S1-S2 normal, regular,
murmur (-)
 Abdomen region : peristaltic(+),tympani,H/L palpable (-)
 Extremities region: warm, swelling (-)
PHYSICAL EXAMINATION
VERTEBRAL REGION
Inspection
Deformity
(+),hematoma (-),
swelling (-),wound (+),
ulcer (+) 15 x 9 cm with
soft tissue base and
necrotic tissue

Palpation
Tenderness (+) as level
L 1 , step off (-)
NEUROLOGIC EXAMINATION
REFLEXES

Physiological Pathological
Reflexes Reflexes

Hoffman/Tromner (-/-) (-
Biceps (N/N) /-)

Triceps (N/N) Openheim (+/+)

KPR (↑/↑) Chaddock (+/+)

APR (↑/↑) Babinski (+/+)

Sacral exam: negative voluntary anal
contraction
LABORATORIUM EXAMINATION

Hasil Hasil
WBC 14,8 [10x3/ul] CT 7’30”
RBC 2,75 [10x3/ul] BT 3’30”
HGB 6,9 [gr/dl] HbsAg Negatif
HCT 21,0 [%] Albumin 1,8
PLT 817 [10x3/ul] GDS 70 [mg/dl]
RADIOLOGIC EXAMINATION
DIAGNOSIS
 Paraplegia due to Complete Spinal Injury ec Burst
Fracture Vertebra Lumbal 1 and Compression Fracture
Vertebra Thoracal 12

 Decubitus Ulcer Stage III

TREATMENT
 IVFD
 Antibiotic
 Plan for decompression and posterior stabilisation
DISCUSSION
 ANATOMY OF THE SPINE

Seeley Stephen. Anatomy and Physiology, 6th Edition. The McGraw-Hill Companies, 2004.
Thompson JC. Spine. In: Thompson JC, editor. Netter’s Concise Orthopaedic Anatomy. Second ed.
China: Saunders Elsevier 2010. p. 29-74.
  Damage to the neural elements due to trauma or disease
resulting in neurological deficit.
 Paralysis

 Loss of sensation

 Loss of body reflexes, micturation & defecation.

Solomon Louis. Apley, System of Orthopaedics and Fractures. 9th Edition. Butterworths
Medical Publications. 2010
MECHANISM OF INJURY

a. Axial compression forces usually result in compression or burst fractures.

b. Flexion forces may result in compression or burst fractures or, if the force
is severe, Chance injuries.
c. Lateral compression forces usually result in lateral wedge fractures, which
are asymmetric compression and burst fractures.
d. Shear forces tend to produce unstable injuries such as fracture-
dislocations.
e. Extension forces usually cause injuries in ankylosed spines but occasionally
may cause injuries in patients with normal spinal anatomy.
f. Flexion-distraction combined forces cause Chance fractures and Chance
variant injuries.
g. Flexion-rotation forces cause a variety of fracture patterns involving
vertebral body fracture and disruption of the posterior elements.
Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System
of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p.
453-91.
 FORCE INVOLVED IN SPINAL
INJURY

Flexion-Distraction Flexion Extension

DENNIS CLASSIFICATION

The three columns of the spine, as proposed by Francis Denis. The anterior column (A) consists of the
anterior longitudinal ligament, anterior part of the vertebral body, and the anterior portion of the
annulus fibrosis. The middle column (B) consists of the posterior longitudinal ligament, posterior part
of the vertebral body, and posterior portion of the annulus.The posterior column (C) consists of the
bony and ligamentous posterior elements. (Modified from Denis F. The three-column spine and its
significance in the classification of acute thoracolumbar spinal injuries. Spine 1983;8:817–831.)

Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition, chapter 3. USA: Lippincot Williams &
Wilkins.2010
SPECIFIC INJURY OF THORACOLUMBAL
 Compression

 Burst

 Flexion-distraction injury ( Chance Fractures)

 Fracture-dislocation

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System
of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p.
453-91.
Compression fracture
 Hyper flexion or
compressive failure
 Anterior column
 Stable injury

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of
Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.
Burst fracture
 Failure of anterior and
‘middle’ columns
 Predominantly axial load
 No posterior column
disruption
 Stable injuries
 < 50% retropulsion
 <20 degrees kyphosis

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's
System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company;
2010. p. 453-91.
Flexion-Distraction Injury
 Due to distraction
forces of middle and
posterior columns
 Usually secondary to
seat belt injuries
 Boney, purely soft tissue,
mixed
 Visceral injuries
common

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopaedics and
Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company; 2010. p. 453-91.
Fracture-Dislocation
 Anterior and cranial
displacement of the
superior vertebral body
with failure of all three
columns
 SPINAL INJURY

SCI BONY INJURY

COMPLETE INCOMPLETE STABLE UNSTABLE

CENTRAL ANTERIOR POSTERIOR BROWN

CORD CORD CORD SEQUARD
PHYSICAL EXAMINATION

 Back pain and tenderness

 Lacerations, abrasions and contusions on the
back

Lauerman WC, Baumbusch CC. Spine. In: Miller MD, Thompson SR, Hart JA, Cosker T, Elyased S, editors.
Review of Orthopaedics. Sixth ed. United States of America: Elsevier Saunders; 2012. p. 589-621.
NEUROLOGIC EXAMINATION
 The Neurologic examination for thoracolumbar
includes :
 Dermatomal sensory testing
 Motor function
 Reflex examination

Spinal Shock refers to flaccid paralysis due to a physiologic

disruption of all spinal cord function

Lauerman WC, Baumbusch CC. Spine. In: Miller MD, Thompson SR, Hart JA, Cosker T, Elyased S, editors.
Review of Orthopaedics. Sixth ed. United States of America: Elsevier Saunders; 2012. p. 589-621.
ASIA Impairment SCALE
A – Complete: no sensory or motor function preserved in
sacral segments S4 – S5

B – Incomplete: sensory, but no motor function in sacral

segments

C – Incomplete: motor function preserved below level

and power graded < 3

D – Incomplete: motor function preserved below level

and power graded 3 or more

E – Normal: sensory and motor function normal

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's
System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company;
2010. p. 453-91.
SACRAL SPARING
 Perianal sensation

 Rectal tone

 Great toe flexion

Eisenstein S, Tuli S, Govender S. The Back. In: Solomon L, Warwick D, Nayagam S, editors. Apley's
System of Orthopaedics and Fractures. Ninth ed. London: Hodder Arnold an Hachette UK Company;
2010. p. 453-91.
RADIOLOGIC EVALUATION

 Thoracolumbal AP and Lateral radiographs.

 CT Scan or MRI  assess canal compromise
and evaluate the degree of neural
compression.
 CT scan – bony injuries
 MRI – soft tissue imaging:
Spinal cord, intervertebral discs,
ligamentous structures

Raymond J. Gardocki, et all. Spine. Campbell Operative Orthopaedics 8th Edition. Mosby, An
Imprint of Elsevier.
PRINCIPLES OF TREATMENT
 To preserve neurological function

 To minimize a perceived threat of neurological

compression

 To stabilize the spine

 To rehabilitate the patient

Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition,
chapter 3. USA: Lippincot Williams & Wilkins.2010
TLICS
(Thoraco Lumbal Injury Classification and
Severity Score)
Injury Characteristic Neurologic status
• Compression (1) • Intact (0)
• Burst (2) • Nerve root (2)
• Rotation (3) • Spinal cord complete (2),
• Distraction (4) incomplete (3)
• Cauda equine (3)

Posterior Ligament
Complex
• Intact (0)
• Suspected (2)
• Disrupted (3)
PROTECTION OF REMAINING NEUROLOGY

 Non-Operative:
 Steroids (Metylprednisolon)

 Operative:
 Decompression

 Stabilization

Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition,
chapter 3. USA: Lippincot Williams & Wilkins.2010