Beruflich Dokumente
Kultur Dokumente
CME ON-
& Management
1
Supervised By-
FROM-
Department of Orthopedics & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka -1207,
Section5
Section6 Section7
Introductions of Spine Spinal Injury (SI) Patho-physiology of Spinal Injury Fundamentals of Assessment & Diagnosis- Spinal Injury Patients Management of Spinal Injury Patients. Rehabilitation of SI Patients Conclusions
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&
Section- 1
found Clear evidence of spinal disorders in prehistoric times. At the end of antiquity ( 7th century A.D.), Paulus of Aegina (625690 A.D.) performed the first successful laminectomies. At the beginning of the 21st century, spinal surgery has become more evidence based, but it is still technology driven in many areas. 5
Section- 1
Section- 1
Introductions of Spine Spine consists of alternating Bony vertebrae Fibrocartilaginous disc Supported by musculature. Motion segment Two adjacent vertebrae with intervening disc.
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Anatomy of Spine:
The Spine is an intricate structure of bones, ligaments, muscles, nerves, and tendons. Its anatomy can be broadly divided into
Hard Bony Part The backbone, or spine, is made up of 31 bony segments called vertebrae: o 8 cervical (neck) vertebrae o 12 thoracic (middle back) vertebrae o 5 lumbar (lower back) vertebrae* o 5 sacral (lowest area of the back) vertebrae 8 o 1 coccygeal (coccyx, or tailbone)
Anatomy of Spine:
Soft Tissue Part
Spinal Cord Inter vertebral disc Muscles Tendon ,Ligaments Nerve Vessels 9
Anatomy of Spine:
Section- 1 Introductions of Spine
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Anatomy of Spine:
Section- 1 Introductions of Spine
Spinal Muscles -
Muscles around the spine play a key role in the health of the back. It support the trunk and hold the body upright. They also allows the trunk to move, twist and bend in multiple directions. Three types of back muscles that help spinal function are the: Extensor muscles- They include the large muscles in the lower back (erector spinae), which help hold up the spine, and gluteal muscles.
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Anatomy of Spine:
Section- 1 Introductions of Spine
Spinal Muscles -
Anatomy of Spine:
Section- 1 Introductions of Spine
Spinal Ligaments -
Normal Anatomy and Composition Ligaments surrounding the spine provide intrinsic stability to the spine and limit motion in all planes. The spinal ligament complex includes: Interspinous Ligaments Supraspinous Ligaments Intertransverse Ligaments Yellow Ligaments (Ligament 13 Flavum)
Anatomy of Spine:
Neurovascular Components-
Blood supply
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Anatomy of Spine:
Neurovascular ComponentsVeins Supplying Spinal Column-
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Anatomy of Spine:
Anatomy of Spine: Spine & Nervous system
Neurovascular Components-
At the level of each spinal bone exits a spinal nerve. Each spinal nerve controls a variety of body functions. Functionally these nerve functions are very specific. Anatomically these nerves are closely attached to vertebral 16 body
Section- 1
Introductions of Spine
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Age-Related Changes of the SpineThe spinal column degenerates far earlier than other musculoskeletal tissues Age-related changes of the spine are not synonymous with painful alterations Time course and probability of early disc degeneration are largely determined by genetic disposition The intervertebral disc is the largest avascularstructureof the human body resulting in large diffusion distances to allow for disc nutrition Compromised disc nutrition is a key factor for disc degeneration Changes in the matrix components of the 18 intervertebraldisc, especially the
Core Messages
Orientation and misalignment of the facet joints correlate with development of early Age-Related osteoarthritis of the joint Changes of the Spine Changes in bone architecture of the vertebral bodies and formation of osteophytes alter mechanical properties of the spinal column Changes in matrix molecules and fiber orientation in ligaments alter behavior of the ligaments Age-related changes of the three joint 19
decreasing ability of somatic cells to replicate, repair, and maintain tissue Apoptosis (programmed cell death), leading to decreased cell numbers in the affected tissue Accumulation of post-translational modifications of matrix proteins, leading to altered properties of the extracellular matrix Increasing generation of oxidative stress due to generation of reactive oxygen species (ROS), leading to cell damage Genetic predisposition, leading to 20 premature aging or phenotypic changes in
Core Messages
leading to altered tissue environment and response of tissue to use and injury General age-related changes, such as a decrease in reaction time, proprioception, vision, hearing, pulmonary and cardiovascular function, leading to decreased mobility and therefore affecting the musculoskeletal system Socioeconomic and psychosocial factors also contribute, mainly by 21 influencing the individual variation
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Stability of Spine-
Biomechanics of Spine -
Anterior column = anterior 2/3 of the vertebral body, disc, and annulus, and the anterior longitudinal ligament) Middle column = posterior 1/3 of the vertebral body, disc, annulus, and the posterior longitudinal ligament Posterior column = pedicles, laminae, facets, capsule, and the interspinous and supraspinous ligament. Spinal injury is said to be stable if only one of the columns is involved. Damage to two or more columns or risking neurological injury (i.e. damage to the middle5 23 column) - unstable.
Section- 1
Spine Unit -
Introductions of Spine
The smallest anatomical unit of the spine which exhibits the basic functional characteristics of the entire spine is called the motion segment or functional spine unit
24 Schematic representation of a functional spinal unit (motion segment) in a the cervical and b lumbar spine.
majority of the vertical compressive loads The vertebral endplate plays an important role in mechanical load transfer and the transport of nutrients Axial disc loads are borne by hydrostatic pressurization of the nucleus pulposus, resisted by circumferential stresses in the anulusfibrosus 25 proximately 1020% of the total
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associated with spinal cord injury These bony injuries include: Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae Other injuries may include: Sprains- over-stretching or tearing of ligaments 28 Strains- over-stretching or tearing of
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most common causes of spinal injuries are: Motor vehicle accidents Acts of violence Falls - Spinal injury after age 65 is most often caused by a fall. Sports and recreation injuries. Diseases- Cancer, arthritis, osteoporosis and cause spinal injuries. inflammation of the spinal cord also can
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Incomplete injury: Some motor or sensory functions is spared distal to the cord injury. Voluntary sphincter contraction, toe flexor contraction present. Prognosis-Good Complete injury: Total motor & sensory loss distal to the injury after Spinal shock (usually lasts for 24-48 hrs) is over. When the bulbo-cavernosus reflex is positive & no sacral sensation or 32 motor function has returned, paralysis
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Denis Classification
Denis defined four types of spinal fractures:
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Types of Spinal InjuryCompression fracture Flexion distraction Burst fracture Chance fracture Translation injury
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15 % Lumbosacral area
Approximately 10% of pts w / C
spine fracture have a second noncontiguous vertebral column fracture Five percent of brain-injured pts have associated spinal injury, 35 While 25% of spine injury patients
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Pattern: A. Primary lesion occur between C5 & C7 with secondary injuries at T12 or the lumber spine. Pattern : B. Primary injury at T2-T4 with secondary injury in cervical spine. Pattern : C. Primary injury occur between T12 & L2 with secondary injuries from L4 -L5.
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Spine Spinal Canal Stenosis Down's Syndrome Klippel- feil Syndrome Arnold- chiari Malformation Metastatic CA Osteomyelitis 37 Rheumatoid Arthritis
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Epidemiology
Mean age 33 yrs 75% males 50% of SCIs are complete 50-60% of SCIs are cervical Immediate mortality for complete cervical SCI ~ 50%
Occurs primarily in young males (> 75% of cases) Half of these injuries result from MVAs 2/3 of patients are < 30 years old Other sources of SCI: Falls, sporting and industrial accidents, gunshot wounds. Most common vertebrae involved are C5, 38 9 C6, C7, T12, and L1 because they have the greatest ROM.
Risk factors:
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Epidemiology Incidence
18 - 35 years Male - 3:1 RTA 51% - cars Domestic 16% Industrial 11% Sports 16% - diving incidents Self harm 5%
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Spinal injury (SI) is an insult to the spine resulting in a change, either temporary or permanent, in its bone structure or soft tissue (Spinal cord, disc, nerves, ligaments or muscles) and/ or motor, sensory, or autonomic function.
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Section- 3
Patho-physiology Of Spinal Injury -
Most likely to occur at sites of maximum mobility Adults C6 Children <8 yrs old C2.
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Patho-physiology Of Spinal Injury -
25% of spinal cord injuries occur after primary injury. Primary injury results from focal injuries (e.g. avulsion, contusion, laceration and intra-parenchymal hemorrhage) and diffuse lesions (e.g. concussive and diffuse axonal injury). Further mechanical disruption can result from external compression or angulation and ischemic damage from occlusion of 42 arterial supply.
Section- 3
Patho-physiology Of Spinal Injury Results from:
Cellular hypoxia Oligaemia
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Patho-physiology Of Spinal Injury -
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Section- 3
Patho-physiology Of Spinal Injury -
Primary Neurological damage Direct trauma, haematoma& SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis Secondary damage Hypoxia Hypoperfusion Neurogenic shock 46 Spinal shock
Section- 3
Patho-physiology Of Spinal Injury Secondary -
Hypoxia
Lesions above C5 damage to
Injury
diaphragm leads to 20% reduction in vital capacity Rx Phrenicn. pacing Lesions at D4-6 reduces vital capacity if < 500ml patient is ventilated Intercostal nerve paralysis Atelectasis poor cough V/Q mismatch Reduced compliance of lung muscle 47 fatigue.
Section- 3
Patho-physiology Of Spinal Injury Secondary -
Neurogenic shock
Lesions above D6 Minutes hours (fall of catecholamines may
Injury
take 24 hrs) Disruption of sympathetic outflow from D1 L2 Unapposed vagal tone Peripheral vasodilatation Hypotension, Bradycardia& Hypothermia BUT consider haemmorhagic shock if injury below D6, other major injuries, 48 hypotension with spinal fracture alone
Section- 3
Patho-physiology Of Spinal Injury Secondary -
Spinal shock
Transient physiological reflex
Injury
depression of cord function concussion of spinal cord Loss anal tone, reflexes, autonomic control within 24-72hr Flaccid paralysis bladder & bowel and sustained Priapism Lasts even days till reflex neural arcs below the level recovers.
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Section- 3
Patho-physiology Of Spinal Injury -
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Section- 4
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FNAC
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Clinical features Pain Breathing difficulty Sensitivity to stimuli Muscle spasms Loss of sensation Loss of reflex function Loss of autonomic activity Loss of bowel control Loss of bladder control Sexual dysfunction Loss of function, such as mobility or sensation 54 Paralysis.
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Clinical features
Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function. Motor level = the last level with at least 3/5 (against gravity) function NB: this is the most important for clinical purposes Sensory level = the last level with preserved sensation Radiographic level = the level of fracture on plain X-Rays / CT scan / MRI NB: spine level does not correspond to spinal cord level below the cervical region. 55
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Patient Assessment
History Previous cardiovascular
problems Pulmonary diseases Endocrine dysbalance Hepatic dysfunction Renal insufficiency Neurological illness
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
A physical assessment is
Physical Examination
mandatory to detect putative intraoperative complications The physical examination complements the history and helps to detect abnormalities not apparent from the history. Examination of healthy asymptomatic patients should minimally consist of measurement of vital signs 57 (blood pressure, heart rate,
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Skin Shape and posture Feel Tenderness Move Flexion / Extension Rotation / Lateral flexion
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Examination of Spine
Signs with patient lying face
downwards Bony outlines Tenderness Sensations and Power Femoral stretch test Signs with patient lying on his back Straight leg raising test (sciatic stretch) Neurological examination of lower 59 limbs
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
OrganSpecific Assessment
Airway Assessment A careful airway assessment
should be made with regard to: Previous difficulty in intubation Degree of mouth opening Size of the tongue Visibility of the pharynx The state of dentition Restriction of neck movement Stability of the cervical spine 60
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Respiratory System
to the extent of the surgical procedure and the preoperative patient Condition, the respiratory function should be assessed with pulmonary function Testing including blood gas analysis in patients with: Asthma Chronic obstructive pulmonary disease Chronic intrinsic restrictive pulmonary diseases such as fibrosis and sarcoidosis 61 Extrinsic restrictive pulmonary
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Cardiovascular Assessment
cardiac morbidity is one of the major challenges for the anesthetist. The elderly patient population presenting for spinal surgery has substantially increased over the last decade. Consequently, the incidence of spinal surgery in patients with coronary heart disease has increased. Special attention must be paid to those patients at increased risk and where coronary heart disease has not been formally assessed. This patient population represents the vast majority. As well as surgery-related risk, is recommended as its predictive value has been confirmed to62 be very high in elective non-cardiac surgery.
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Neurological Assessment
A neurological examination of the patient
should be made preoperatively including Assessment of gait, motor or sensory deficits and reflexes. This should be documented since the anesthesiologist has a responsibility to avoid further neurological deterioration during maneuvers such as tracheal intubation and patient positioning. Congenital kyphosis and scoliosis, postinfectious scoliosis, neurofibromatosis And patients with skeletal dysplasias carry an increased neurological risk as well as 63 patients with neurological deficits prior to
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Routine Pre-operative Investigations1. Routine Blood tests. 2. Kidney, Liver function tests. 3. Lungs, Heart and Neurological assessments. Bone pathology
specific Investigations-
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Radiological Evaluation -
The diagnosis of spine conditions or diseases is based on several factors including history of pain, evaluation an physical examination, and specific diagnostic tests. Each has advantages and disadvantages, and a specific purpose. Testing may include one or more of the following: Plain x-rays
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X-RAY
X-rays of the spine reveal bone changes such as those seen in arthritis or scoliosis (curvature of the spine). They do not show nerves or discs. Helpful in diagnosing Bone spurs, Malignancy, Infection, or Dual Fractures. Absorptiometry (Dexa Energy X-ray scan) : Dexascan is used specifically to assess a patients risk of fracture by detecting osteoporosis of the vertebral bodies, which is a thinning of the bones as we age and a possible source of Bone 66 disorders.
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Fundamentals of Assessment & Diagnosis of Spinal Injury -exam Screening
Stenosis cannot be diagnosed
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
CT - SCAN
Excellent Bony Detail
Difficult to diagnose stenosis
Replaced by MRI
May be useful for those who cannot have an
MRI
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MYELOGRAPHY
Fundamentals of Assessment & Diagnosis of Spinal Injury Invasive 1% spinal headache Recurrent stenosis Inability to obtain MRI
Excellent for intra-canal pathology Poor for foraminal pathology Replaced by MRI
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
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Fundamentals of Assessment & Diagnosis of Spinal Injury Image showing a normal disc at level L4/5 (Adams I) and severe disc degeneration with contrast medium in the spinal canal of L5/S1 (Adams V).
Discography -
Disc alterations Disc degeneration Annular tears (high intensity zones) Endplate changes (modic changes) Minor disc protrusions with 70
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
MRI- OR - CT scan
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Fundamentals of Assessment & Diagnosis of Spinal Injury -
Bone scans provide surgeons with a detailed assessment of areas of abnormal bone activity. This test can be important for diagnosing spinal problems such as: Tumor Infection Fracture Arthritis or inflammation Bone scans are highly sensitive and can reveal abnormalities that are too small to appear on 74 other tests such as x-rays, MRI's, or CT Scans.
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Fundamentals of Assessment & Diagnosis of Spinal Injury Nerve conduction studies
EMG-NCS
Electromyography
EMG is likely of greater utility in FBSS than in primary low back pain and sciatica. Greatest use is for establishing the presence of a peripheral neuropathy May be helpful for defining a feigned neurological deficit 75 Rarely using in decision-making
Fundamentals of Spinal Injury Management Medical Management Conservative (General) Conservative (Medical) Surgical Management
Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation
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Section- 5
Section- 5
Fundamentals of Spinal Injury Management-
Medical Management
Conservative Aim is to prevent extension of (General)primary injury, to reduce secondary injury and to treat complicationsConservative Follow ATLS principles(Medical)Airway; protect Spine Breathing Circulation Disability, Dx and Rx shock Ease patient & Treat Secondary survey. 77
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Section- 5
Fundamentals of Spinal Injury Management-
(Pre-hospital) management-
Initial treatment of patients with cord injury focuses on two aspects preventing further damage and resuscitation.
Immobilization with a hard cervical collar (in case of cervical spine injuries) and care in transportation of patient is of paramount importance if the spine is unstable.
Resuscitation is aimed at airway maintenance, adequate oxygen saturation of peripheral blood, restoring blood pressure to acceptable limits, preventing bradycardia, done 78 simultaneously to prevent any ischemic
Section- 5
Fundamentals of Spinal Injury ManagementImmediate ManagementGoals:
Conservative(General) Resuscitation according to ATLS guidelines . Determination of neurological injury Prevention of neurological deterioration. Ongoing ID & Tx of assoc injuries Prevention of complications Initiation of definitive management 79 32 for
Section- 5
Fundamentals of Spinal Injury Management-
Conservative (General)
Breathing beware patient with C3,C4 or C5 lesion who initially has adequate respiratory effort who may progress to ventilatory failure Circulation Shock common but spinal shock is a diagnosis of exclusion CVP/PAWP monitoring usually unnecessary Immobilization Cervical spine should be immobilised in neutral position (ie position obtained when looking straight ahead) Children <8 yrs may require back elevation 80 with padding to achieve this position.
Section- 5
Fundamentals of Spinal Injury Management-
Conservative (Medical)-
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Section- 5
Fundamentals of Spinal Injury Management-
Conservative(Medical)Conservative treatments of spinal disorders have improved significantly over the years. Of the many conservative non-surgical treatments that are currently available, a few of the most commonly practiced treatments are Epidural Steroid Injection Intradiscal-thermoplasty (IDET) Nucleoplasty Facet Injections, and/or Medial Branch Blockade 82 Radio Frequency
Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management Conventional Spinal Surgery Minimally Invasive Spinal Surgery Endoscopic Spinal Surgery Laser Spinal Surgery Intra-discal electrical Surgery
Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation
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Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Depending on the
circumstances, when surgery is required. Surgery may be considered if the spinal cord is compressed and when the spine requires stabilization. The surgeon decides the 84 procedure that will provide the
Section- 5
Fundamentals of Spinal Injury Management-
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Section- 5
Fundamentals of Spinal Injury Management-
Spinal Decompression
Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots. Discectomy
Laminectiomy Laminiotomy Foraminectomy Foraminiotomy
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Section- 5
Fundamentals of Spinal Injury Management-
Spinal Decompression
Section- 5
Fundamentals of Spinal Injury Management-
Decompression of the neural elements (spinal cord/nerves) Stabilization of the bony elements (spine) Timing Emergent Incomplete lesions with progressive neurologic deficit
Elective Complete lesions (3-7 days post injury) 88 Central cord syndrome (2-3 weeks
Section- 5
Fundamentals of Spinal Injury Management-
Spinal Stabilization
Vertebroplasty
Kyphoplasty
Total Disk Replacement
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Section- 5
Fundamentals of Spinal Injury Management(Also known as spondylodesis or spondylosyndesis)
Spinal Fusion
Spinal fusions are considered medically necessary for spinal instability associated with any of the following conditions: Epidural compression or vertebral destruction from tumor Idiopathic scoliosis over 40 degrees Instability after debridement for infection Neural compression after spinal fracture Pseudarthrosis Spinal infections (including tuberculosis, osteomyelitis, discitis) Acute cauda equine OR acute spinal cord compression syndrome Acute spinal fracture from documented trauma. Intra-operative spinal instability. 90
Patients requiring spinal fusion have either neurological deficits or severe pain which has not responded to conservative treatment.
Section- 5
Types of spinal fusion
Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision Posterior lumbar interbody fusion (PLIF) - the disc is accessed from a posterior incision Transforaminal lumbar interbody fusion 91 (TLIF)
Section- 5
Fundamentals of Spinal Injury Management-
Dynamic
Spine Stabilization
Spinal Stabilization
Indications Herniated disc, Spinal stenosis, Degenerative Disc Disease. Spinal Stenosis is blockage in the spinal canal and associated nerve ways. A Herniated Disc (commonly known as "slipped disc") is when a spinal disc loses its normal shape as can cause pressure on nerves and this results in pain, numbness, and tingling. Dnamic spine stabilization is not appropriate for everyone and as with any 92 surgery there are possible complications.
Section- 5
Fundamentals of Spinal Injury Management-
a . Dynamic posterior spinal stabilization with Dynesys (Image Zimmer, Inc. used by permisson. b . Interspinous process distraction devices (e.g. X-stop) limit extension motion and unload the facet joints. The aim is to improve functional spinal stenosis by indirect widening of the 93 spinal canal.
Section- 5
Fundamentals of Spinal Injury ManagementCore Messages
Spinal Instrumentatio n-
Section- 5
Fundamentals of Spinal Injury ManagementCage designs
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Fundamentals of Spinal Injury Management-
Surgical Management -
Section- 5
Fundamentals of Spinal Injury Management-
Spinal Fixation
Spinal fixations are considered medically necessary for spinal instability associated with any of the following conditions:
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Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Spinal Instrumentation -
Section- 5
Fundamentals of Spinal Injury Management-
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Fundamentals of Spinal Injury Management-
Surgical Management -
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Section- 5
Fundamentals of Spinal Injury ManagementFundamentals of Spinal Injury Management-
Surgical Management -
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Fundamentals of Spinal Injury Management-
Stand-alone intervertebral cages for spinal fusion exhibit poor stabilization in extension. a Extension is normally partially limited by the facet joints. b Following the insertion of an interbody cage, the facet joints may 102 be distracted, c thereby increasing segmental mobility.
Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Current intervertebral disc prostheses differ in the bearing material used (polyethylene or metal alloys) and have either a fixed (constrained) Center of rotation - (e.g. a Prodisc, Synthes) or follow the segmental helical axis of motion (semi-constrained) as in b the Charit e prothesis (DuPuy Spine Inc.).
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Section- 5
Fundamentals of Spinal Injury Management-
complications but can be minimized with proper post-operative care. Despite advances in anesthesia care and surgical techniques, major surgery is still prone to undesirable consequences such as:
Infection
Thromboembolic complications Cardio-respiratory morbidity Cerebral dysfunction Postoperative nausea and vomiting Gastrointestinal paralysis Pain 104 Fatigue
Section- 5
Fundamentals of Spinal Injury The Management
necessity for careful postoperative assessment of the different organ systems is self-evident Perioperative tachycardias are often combined with ischemic episodes, and their treatment is mandatory because of the high mortality of perioperativemyocardiac infarction Intensive insulin therapy can reduce morbidity and mortality Following cervical spine surgery, perform airway assessment before extubation. Suction drainage and close surveillance minimize the risk of unrecognized bleeding Aggressive postoperative pulmonary care minimizes the 105 risk of respiratory complications
Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Patients about whether they should see an orthopedic surgeon or a neurosurgeon. The spine is an area of territorial overlap between these two surgical disciplines. In general, degenerative disease of the neck is more likely to be referred to a neurosurgeon while the more complex disorders of the lumbar spine, particularly those requiring fusions, will probably be 106 dealt with by an orthopaedic surgeon.
Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Section- 5
Fundamentals of Spinal Injury ManagementFundamentals of Spinal Injury ManagementCore Messages
procedure is key to surgical success An in-depth knowledge of the surgical anatomy is a prerequisite for successful surgery. Detailed anatomical knowledge helps to avoid serious complications. 108
Section- 5
Fundamentals of Spinal Injury Management-
Surgical Management -
Surgical Approaches -
Rehabilitation
Section- 6
Rehabilitation after spinal injury (SI) focuses on the patient learning how to live life when faced with physical, occupational, and emotional challenges. After SI, everything can change, and you can face many issues including mobility, regular exercise and maintaining a level of fitness, communication challenges, and activities of daily living. Rehabilitation may be accomplished at 110 a hospital, outpatient clinic, home, or a
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Rehabilitation
Accredited rehabilitation centers provide SCI patients with a team of professionals and many resources. Some of the professionals include:
Occupational Therapist Physiatrist. Physical Therapist: Rehabilitation Nurse. Speech and Language Pathologist. Therapeutic Recreational Specialist. Vocational Rehabilitation Therapist. Rehab Psychologist
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Rehabilitation
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Rehabilitation
Neurological disorders are the most complicated problems known to medical science today, and we require the best scientific minds and technology in order to find cures.
W. Dalton Dietrich, Ph.D., scientific director, The Miami Project to Cure Paralysis
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Prognosis
The main determinant of outcome is the patient's neurological grade at the time of admission with patients having complete motor and sensory myelopathy showing the worst prognosis. Other predictive factors include rectal tone status, admission blood pressure and pulse status, reflexes, and medical and surgical management since injury. The time course of recovery is also prolonged and recovery itself often incomplete. Taking all grades and locations into considerations a study concluded that while the majority of cases improved within a year, even at 3 years post injury 23.3% continue to improve whereas 7.1% deteriorated. The trend continued in the 5th year post injury also with 12.5% and 5.5% respectively showing further improvement and late deterioration. Hence 114 prolonged rehabilitation at a comprehensive spinal rehabilitation center is the management of spinal cord injuries.
Core Messages
The most commonly examined predictors of surgical outcome can categorized into the following groups -
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Health behavioral and lifestyle factors Smoking (especially for fusion) Psychological factors Psychological distress (e.g. Depression, anxiety), especially in patients with chronic pain Sociological factors- Family reinforcement of pain, especially 116 in patients with chronic pain
Complications of Spinal Injury/Surgery Skin Breakdown Osteoporosis and Fractures: Pneumonia, Atelectasis, Aspiration: Heterotopic Ossification: Spasticity: Autonomic dysreflexia: Deep vein thrombosis: Cardiovascular disease: Syringomyelia Neuropathic/Spinal Cord Pain Respiratory Dysfunction Miscellaneous pressure sores, Greatly increase cost and morbidity. Pokilothermia in patients with lesion above T1hyponatraemia common in 117 first week.
Complications of Spinal Injury There are many complications of spinal Injury the followings are most common -
There are many complications of spinal Surgery, the followings are most common -
General Complications Anesthesia Complications Bleeding Infection Blood Clots CSF leak / Dural Tear Lung Problems Persistent Pain Nerve Complications Nerve Injury Spinal Cord Injury / Paresis /Paralysis Sexual Dysfunction / Incontinence Implant & Fusion Complications Delayed Union or Nonunion Hardware Fracture Implant Migration 118 Pseudarthrosis
Recent Trends in Spine Surgery Minimally Invasive Surgery(MIS) Dynamic stabilization- Motion prevention Artificial disc replacement Endoscopic Spinal Surgery Laser Spinal Surgery Intra-discal electrical Surgery And Bio-absorbable Implant implantation
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Pre-hospital & hospital both phases are equally Section- 7 important for SI management. Surgical intervention improves recovery period, quality of life and Rehab, reduces morbidity/ mortality . SI is neglected and poorly managed. Research is sparse and data is missing. The demographics, epidemiological pattern of SC in the developing world is different from the developed world and this should be considered while formulating polices for the SI in future. Trauma evacuation protocols need to be developed and pre hospital care of suspected SI patient should be improved. Regional and national spinal injury centers 120 providing comprehensive treatment and
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Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' &traumatology-
Diagnosis
Operation
Total case 44
1.
PLID
(Prolapsed inter-vertebral disk).
Surgical
decompression/Discectomy/ Laminectomy/Epidural steroid).
2. 3. 4. 5.
Spinal TB/ Spinal Collapse. Spinal Injury Spinal Tumor Spinal Osteomyelitis
13 5 10 13
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' & traumatologySpinal Tumor 6% Spinal TB/ Collapse 16% Other 28% PLID 50% Others 16%
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Depa rt m ent o f o rt ho pedics & t raum at ology Diagnosis operation Total case 35
1.
PLID
(Prolapsed intervertebral disk).
Surgical
decompression/Discectomy/Lamin ectomy/Epidural steroid).
2.
Spinal Fixation
14
3.
4. 5.
Spinal Injury
Spinal Tumor Spinal Osteomyelitis
Spinal Fusion
Spinal Tumor Removal Clearance
9
3 10
Statistical data of Spinal disorder operated at Shaheed Suhrawardy Medical College Hospital, Department of orthopedics' & traumatology -
Spinal Tumor
17%
11% 16% 12% 56% 4%
Case -1
Spinal Surgery:
At Shaheed Suhrawardy Medical College Hospital, Dhaka.
Patient Name: Ms. Jhorna Begum, Age:17 years. Indication/ Diagnosis: Spinal TB with compression # body of L3 with posterior angulations - 45 ( on TB medication for 6 weeks) & history of fall. Name of operation: Clearance & Spinal fixation with rod and pedicle screw. Dated: 23rdJuly/ 2011. Venue: Shaheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh. Department Of Orthopedics' &Traumatology. Team Members: Associate Professor Dr. Sheikh AbbasUddin Ahmed Associate Professor Dr. Paritosh Ch. Debenath Assistant Professor Dr. Kazi Shamimuzzaman Assistant Professor Dr. ATM BaharUddin Dr. Aminur Rahman Anesthesiologist :
Case -2
Case -3