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3424847-spine

3424847-spine

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Published by Jen Koot

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Published by: Jen Koot on Sep 14, 2012
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01/18/2013

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Spine-General Principles
 
Spine-General Principles
Main concern in any spinal injury is not spine itself but neurological elements (spinal cord, nerveMain concern in any spinal injury is not spine itself but neurological elements (spinal cord, nerve roots and cauda equina).roots and cauda equina).
If there is no neurological complication, precautions must be taken to see that this is avoided at allIf there is no neurological complication, precautions must be taken to see that this is avoided at all stages.stages.
If there is incomplete paraplegia, see that no deterioration is allowed to occur.If there is incomplete paraplegia, see that no deterioration is allowed to occur.
If paraplegia is complete, prognosis regarding potential recovery must be firmly established as earlyIf paraplegia is complete, prognosis regarding potential recovery must be firmly established as early as possible.as possible.Spine-Anatomical features
 
Spine-Anatomical features
Elements comprise of vertebral body composed of cancellous bone covered with outer shell of Elements comprise of vertebral body composed of cancellous bone covered with outer shell of  cortical bone, horseshoe-shaped neural arch, 2 articular masses or processes which take part incortical bone, horseshoe-shaped neural arch, 2 articular masses or processes which take part in facet (interarticular) joints, and transverse and spinous processes. These form a protective bonyfacet (interarticular) joints, and transverse and spinous processes. These form a protective bony covering for cord and issuing nerve roots. Neural arch is divided by articular processes into pediclescovering for cord and issuing nerve roots. Neural arch is divided by articular processes into pedicles and laminae.and laminae. 
These vertebra are held together by inter spinous, supra spinous, inter transverse, annular These vertebra are held together by inter spinous, supra spinous, inter transverse, annular  ligaments, facet joint, capsular ligament and ligamentum flavum.ligaments, facet joint, capsular ligament and ligamentum flavum.
IS and SS ligaments are of paramount importance, and form so called posterior ligament complex.IS and SS ligaments are of paramount importance, and form so called posterior ligament complex. If this is torn, other ligaments offer little resistance and spine may sublux or dislocate. SubluxationIf this is torn, other ligaments offer little resistance and spine may sublux or dislocate. Subluxation may also occur if neural arch or articular facets are # and in either case the spine is unstable.may also occur if neural arch or articular facets are # and in either case the spine is unstable. 
In instable spine, neurological structures may be damaged, and of they escape initially, they remainIn instable spine, neurological structures may be damaged, and of they escape initially, they remain at risk and it is vital to ensure that delayed neurological involvement does not occur.at risk and it is vital to ensure that delayed neurological involvement does not occur.
If neural arch, articular facets and PLC remain intact, injury is described as stable, neurologicalIf neural arch, articular facets and PLC remain intact, injury is described as stable, neurological damage is uncommon, and prognosis is generally excellent.damage is uncommon, and prognosis is generally excellent.
Exception include burst # of spine,Exception include burst # of spine, some lateral wedge # and extension injuries of cervical spine.some lateral wedge # and extension injuries of cervical spine.
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Cervical spine-DiagnosisCervical s
 
pine-Diagnosis
C/O of neck, occipital or shoulder pain after trauma, torticollis, restriction of neck movements or C/O of neck, occipital or shoulder pain after trauma, torticollis, restriction of neck movements or  supports head with hands or is unconscious after head injury.supports head with hands or is unconscious after head injury. Cervical spine-Initial managementCervical spine-Initial man
 
agement
First safeguard the cord by controlling neck movements. Simplest is cervical collar. At road side, anFirst safeguard the cord by controlling neck movements. Simplest is cervical collar. At road side, an adequate collar is made from rolled newspaper stuffed into nylon stocking and wrapped round theadequate collar is made from rolled newspaper stuffed into nylon stocking and wrapped round the neck. Head may be supported by sand bags.neck. Head may be supported by sand bags.
Do not allow the head to flex forwards, and do not Do not allow the head to flex forwards, and do not  hyperextend.hyperextend.
In conscious patient quickly check movements in all four limbs.In conscious patient quickly check movements in all four limbs. 
If there is some evidence of neurological involvement,If there is some evidence of neurological involvement,
do not do not 
check range of cervical motion. Takecheck range of cervical motion. Take x-rays supporting the head during positioning (go with the patient) and make sure that spine is notx-rays supporting the head during positioning (go with the patient) and make sure that spine is not forced into flexion. For initial screening, AP, lateral and through the open mouth view of C1 and C2forced into flexion. For initial screening, AP, lateral and through the open mouth view of C1 and C2 should be taken.should be taken.
If these films appear normal, proceed further examination of neck for localizing tenderness,If these films appear normal, proceed further examination of neck for localizing tenderness, restriction of movements and protective spasm and thorough neurological examination. If this isrestriction of movements and protective spasm and thorough neurological examination. If this is normal, patient treated with cervical collar with F/up review in 1 week.normal, patient treated with cervical collar with F/up review in 1 week.
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Cervical spine-Initial managementCervical s
 
pine-Initial management
If there is persistent limitation of movements or evidence of neurological disturbance, 2 more lateralIf there is persistent limitation of movements or evidence of neurological disturbance, 2 more lateral views, one in flexion and one in extension, and right and left oblique views of cervical spine taken.views, one in flexion and one in extension, and right and left oblique views of cervical spine taken. Upper border of T1 must be seen andUpper border of T1 must be seen and
do not accept poor quality films.do not accept poor quality films.
CT if available, mayCT if available, may provide valuable information.provide valuable information.Classification of cervical spine injuriesClassification
 
of cervical spine injuries
 According to mechanism of injury; flexion, flexion and rotation, extension and compression injury. According to mechanism of injury; flexion, flexion and rotation, extension and compression injury.Causes of flexion and flexion rotation injuriesCauses of flexion and flexion rotation injuries
Falls on back of head leading to flexion of neck as in motorcycle spills, diving in shallow water, poleFalls on back of head leading to flexion of neck as in motorcycle spills, diving in shallow water, pole vaulting and rugby football; blows on back of head from falling objects as in building and miningvaulting and rugby football; blows on back of head from falling objects as in building and mining industries; rapid deceleration in head-on car accidents.industries; rapid deceleration in head-on car accidents.Flexion injury: Stable anterior wedge #Flexion injur 
 
y: Stable anterior wedge #
Vertebral body is wedged anteriorly, posterior part is generally intact. Before the injury can beVertebral body is wedged anteriorly, posterior part is generally intact. Before the injury can be declared stable there must be no evidence of injury to posterior ligament complex, no separation or declared stable there must be no evidence of injury to posterior ligament complex, no separation or  avulsion of vertebral spines or clinical evidence of ligament tear, no damage to neural arches or avulsion of vertebral spines or clinical evidence of ligament tear, no damage to neural arches or  facets. In addition, flexion and extension lateral views must be taken which confirms no vertebralfacets. In addition, flexion and extension lateral views must be taken which confirms no vertebral instability.instability.
If these criteria are satisfied, neurological disturbance is rare and prognosis is excellent. Treat withIf these criteria are satisfied, neurological disturbance is rare and prognosis is excellent. Treat with cervical collar for 6 weeks. Rarely, when there is lateral wedging there may be troublesome nervecervical collar for 6 weeks. Rarely, when there is lateral wedging there may be troublesome nerve root involvement usually with mainly sensory disturbance in corresponding dermatome.root involvement usually with mainly sensory disturbance in corresponding dermatome.
If instability If instability  is at all suspected, treat it as a cervical dislocation.is at all suspected, treat it as a cervical dislocation.
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