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Cedera spinal

Fanny Indarto, dr. Sp.B

Spinal Cord Injury can occur


without spinal column
injury.
Spinal column injuries can
occur without spinal cord
injury.

Trauma Manual, 3rd edition, 2008

Spinal injury should be


suspected in any patient with a
head injury or severe facial or
scalp lacerations.
In any patient with recent
trauma, complaints of neck pain
or spinal pain should be
considered indicative of a spinal
injury until proved otherwise.
Chambell, 2007

The general assumption is that all


patients have an unstable spine until
proven otherwise.
Patients with continued complaints of
spine-related pain must be
thoroughly evaluated and this
evaluation must be repeated if the
symptoms persist.
Trauma Manual, 2008

Etiology

Trauma, Feliciano, 2008

Spinal injury with neurologic


defisit

Trauma, Feliciano, 2008

Bulbocavernal reflex

The absence of this reflex


indicates spinal shock.
The return of the
bulbocavernosus reflex,
generally within 24 hours
of the initial injury,
hallmarks the end of spinal
shock. ( Handbook of Fracture, 2006)

Complete paralysis
Preservation of vibration
and touch sensations
The prognosis for recovery
is poor, with minimal chance
of return of meaningful
function.57
Tetraparesis with arms,
and in particular hands,
weaker than legs
Variable sensory loss that
does not involve the face

Ipsilateral paralysis
Ipsilateral vibration
and touch sensory
loss
Contralateral pain and
temperature loss
Tetraparesis is due to
disruption of the
lateral corticospinal
tracts.
Sensory loss is
profound with the
exception of pain and
temperature.

Spinal Cord Injury


Syndromes

Orthopedic Surgery Essential, 2004

Spinal shock
mostly occurs after significant cervical cord
injury;
characterised by a state of flaccid paralysis,
hypotonia and areflexia (e.g. absent
bulbocavernosus reflex)
The sensory and motor symptoms usually
resolve by 46 h, but autonomic symptoms can
persist for days or weeks
Most typical signs include bradycardia despite
hypotension, flaccid paralysis and lack of painful
sensation to the limbs affected; other

Handbook of Fracture, 2006

Pathophysiology
Disruption of the normal blood flow ischemia in the
gray matter
Although the white matter blood supply may not
diminish, vasospasm can affect the ascending and
descending tracts as arterioles pass through the gray
matter to reach these tracts. Vasoconstriction can
increase progressively over the first 24 hours the
release of histamine, prostaglandins, serotonin, and
neurotransmitters such as norepinephrine.
Thrombosis of injured arteries contributes to ischemia,
which is tolerated poorly by central nervous system
tissue, initiating a cascade of ion derangement,
inflammation, and apoptotic cell death.

Injured cells release proinflammatory


substances that attract neutrophils to the
area within 24 to 48 hours; this causes an
expansion of the damage in the rostral
and the caudal directions.
In 48 hours, macrophages and microglial
cells migrate to the site and release
reactive oxygen radicals that cause
damage to the surrounding healthy tissue.

Cellular membrane breakdown ionic


imbalance and nucleolysis. As the energy
supply necessary for restoration of
membrane potential is depleted, K move
out, and Na move in. Additionally, Ca is
released activates enzymes in the
proteolytic pathway -destroy the
cytoskeletons of cell bodies and axons.
All of these events lead to demyelination
and necrotic cell death.

Imaging
Standard plain radiographic evaluation involves
anteroposterior, lateral, and open mouth views.
Cross Table Lateral View (CTLV), which can depict 70 to 79% of
all injuries.
The lateral film must adequately visualize the entire cervical
spine including the cervicothoracic junction. If the lateral view
is not sufficient, a swimmer's view is obtained. If still unclear,
a computed tomography (CT) scan of C7-T1 is obtained.
Anteroposterior (AP) and the open mouth view increases the
diagnostic yield of plain radiographs to 90-95%.
Radiographs of the thoracic and lumbar spine are indicated for
all patients with multiple injuries, patients who are obtunded,
and patients with neurologic deficits.

On the lateral cervical spine radiograph, one may appreciate:


Acute kyphosis or loss of lordosis.
Continuity of radiographic lines: anterior vertebral line, posterior
vertebral line, facet joint line, or spinous process line.
Widening or narrowing of disc spaces.
Increased distance between spinous processes or facet joints.
Abnormal retropharyngeal swelling, which depends on the level in question:
At C1: >10 mm
At C3, C4: >4 mm
At C5, C6, C7: >15 mm

Radiographic markers of cervical spine instability, including the following:


Compression fractures with >25% loss of height
Angular displacements >11 degrees between adjacent vertebrae (as measured by
Cobb angle)
Translation >3.5 mm
Intervertebral disc space separation >1.7 mm (Figs. 9.2 and 9.3)

Four important lines should be


checked (anterior and posterior
vertebral lines, spinolaminar line,
spinous process line); contour of
vertebra and position of spinous
process (if deviates to one side
implies rotation), distance between
spinous processes.
Ip, 2008

Imaging
CT:
Occult fracture (e.g. lateral
masses)
Degree of retropulsion
Double vertebra sign
suggestive of fracture
dislocation
3D reconstruction, as well
as coronal/sagittal
reconstructions
Ip, 2008

Imaging
MRI advantages can assess:
Disc
Cord (oedema, bleeding)
Ligament (integrity)
Haematoma (e.g. epidural)

Ip, 2008

Spinal cord injuries without radiographic abnormality


(SCIWORA)

Young patients
because of the elasticity of their
ligaments
A central cord-type injury
Should underwent MRI

patients who are completely


asymptomatic with no physical
findings, normal mentation, and no
distracting injuries, proposing that
these patients do not require
radiological evaluation (Pediatric Trauma,
2006)

Cervical Spine
C1 and C2 are referred to as the
axial cervical spine
C1 ring fractures, (Jefferson),
specific patterns of odontoid peg
fractures, and specific pedicle
(Hangman's) fractures of C2.
C3 to C7 represents the subaxial
cervical spine.

Handbook of Fracture, 2006

Thoraco-lumbar Spine
The essential fracture patterns are
wedge, burst, flexion or seatbelt
(chance), or fracture dislocations.

Compression Fracture

Handbook of fracture, 2006

principles of spine injury


management
(1) to avoid the progression of neurologic
defisit
(2) to reduce unacceptable spinal deformity
or malalignment
(3) to maintain spinal alignment within a
functional range
(4) to achieve healing of the spine in a
functional alignment sufficient to permit
return of physiologic loads through the spine.
Trauma, Feliciano, 2008

Pharmacologic Treatment
Methylprednisolone
Ganglioside GM1
Naloxone

Medical Treatment
Patients with acute spinal cord injury should
optimally receive methylprednisolone within
three hours of the injury for a period of 24
hours.79
Patients with methylprednisolone therapy
initiated between three and eight hours from
the time of injury, should continue this regimen
for 48 hours.
Methylprednisolone is widely used in the
treatment of acute spinal cord injury and is
considered by many as the standard of care.

Dose of Methylprednisolone

Orthopedic Surgery Essential, 2004

Immediate spinal
immobilization
In the cervical spine initial immobilization may be
achieved with the use of tongs or halo ring
traction
The goals of traction include reduction of the
deformity, indirect decompression of the
traumatized neural elements, and provisional
stability of the spine.
The urgency of the reduction is based on
experimental studies of spinal cord injuries which
suggest a window of six to eight hours during
which decompression may reverse neurologic
deficits

Immobilization in the thoracolumbar


spine may initially be achieved by
bed rest and log-rolling the
patient. Additionally, these injuries
may be stabilized with the use of a
rigid brace, which in many
instances may also be the definitive
treatment.

Basic cervical orthoses

Surgery
The majority of the spine fractures can be
treated nonoperatively. Only injuries
that are unstable, with or without
neurologic involvement, require surgical
treatment.
Surgical objectives include the correction
of spine alignment; the restoration and
maintenance of spine stability; and the
decompression of compromised neural
elements.

Timing of Surgery
The absolute indications for immediate surgery
are progressive neurologic deterioration and
spine fracture-dislocations associated with
incomplete or no neurologic deficit.
In the absence of neurologic deficit, it is
reasonable to delay surgery to facilitate
surgical planning, and allow for spinal cord and
nerve root edema to resolve.
optimum canal clearance is most effective if
surgery is ideally performed within four days