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TRAUMA MEDULA SPINALIS

Dr. Rendra leonas SpOT
ORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY
MOH. HOESIN PALEMBANG

Introduction
Most common
age and high speed level
traffic accident >>
80% spinal inj not assoc SI
more important preliminary care

At least 5% of patients
With spinal cord injuries
Worsen neurologically at
hospital.

Anatomy and Physiology 33 bones comprise the spine • Function – Skeletal support structure – Major portion of axial skeleton – Protective container for spinal cord • Vertebral Body – Major weight-bearing component – Anterior to other vertebrae components .

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Anatomy and Physiology SPINAL NERVES • 31 pairs of spinal nerves : • 8 cervical • 12 thoracic • 5 lumbar • 5 saccral • 1 coccygeal • Each has both motor and sensory fibers – Motor fibers = anterior or ventral root – Sensory fibers = posterior or dorsal root .

Anatomy and Physiology Components of Vertebrae – Spinal Canal • Opening in the vertebrae that the spinal cord passes through – Pedicles • Thick. bony structures that connect the vertebral body to the spinous and transverse processes .

early ischaemia. peripheral nerves . Anatomy • Spinal cord ends below lower border of L1 • Cauda equina is below L1 • Mid dorsal spinal cord & neural canal space are of same diameter hence prone for complete lesion • Mechanical injury . cord edema - cord necrosis • Neurological recovery unpredictable in cauda equina ie.

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OVERVIEW • LOOK – inspection • FEEL – palpation • MOVE – active & passive movements .

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intervertebral or paravertebral • Bony prominence or steps spinous processes – using C7 &/or L4-5 – as landmarks facet joints – approx. EXAMINATION :STANDING Feel : • Tenderness: may be bony. 2cm lateral to spinous processes .

EXAMINATION : STANDING Feel : assess alignment. mobility & tenderness of: – transverse processes of vertebrae  lateral to spinous processes .

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Signs of nerve root compression Standard full neurological examination of both lower limbs : • tone. power (MRC grading) • sensation (light touch. pinprick & proprioceptive if indicated) • reflexes (physiologic and patologic) • an anatomical distribution [dermatome(s) or myotome(s)] .

Neurological Examination • Objectives : – Determine if defect is present – Localize the level of the deficit • Include : – Sensory – Motor – Reflex .

compare each opposite . • Sensory dermatomes. proprioceptive. 2 point discrimination. eyes closed • Examine : touch. Neurological Examination Sensory examination • Explain.

Sensory Dermatome .

movement is possible when gravity is excluded • 3 . Muscle Power Grading • 0 .flicker of contraction possible • 2 .normal power .complete paralysis • 1 .movement is possible against gravity • 4 .movement is possible against gravity + some resistance • 5 .

Neurological Examination Motor examination • Muscle grading • Compare each side Cervical : Scapular C4 Deltoid & Biceps C5 Wrist extension & supination C6 Wrist flexion & Pronation C7 .

S1.3.2 Knee extensor L 2.3 Hip extensor S1 Knee flexor L 4.5. Neurological Examination Motor examination • Lumbo-sacral Hip flexor L 1.2.4 Ankle flexor S1 Ankle extensor L5 .

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8:1983. Spine. F.) .: The Three-Column Spine and its Significance in the Classification of Acute Thoracolumbar Spinal Injuries. Denis’ 3 Column Theory Denis.

. Cervical spine anatomy • Anterior column . • Middle column – Posterior long. Lig. • Posterior Column – Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.Anterior longitudinal ligament+ Anterior annular ligament and anterior half of VB. + Posterior annular ligament +Posterior half of VB.

Burst fracture Denis’ Classification . Compression fracture 2. Basic Types of Spine Fractures 1.

Seat-belt injury (Flexion-distraction injury) Bony Chance fracture Soft tissue Chance injury . Basic Types of Spine Fractures 3.

Basic Types of Spine Fractures 4. Fracture-dislocation Anterior posterior shear Flexion-rotation Flexion-distraction .

Classification spine fracture • Stable injury : compression fracture burst fracture • Unstable injury : dislocation fracture dislocation chance fracture .

Hangman’s fracture 4. Dens fracture 3. Clay shoveler’s fracture 5. Jefferson fracture 2. Classification spine fracture • Location : 1. SCIWORA .

Compression fracture
• Failure of the anterior column
• Mechanism anterior or lateral flexion
• Normally Stable or unstable fracture
• Rarely involved neurologic comprimise

Criteria unstable

• Loss of 50% of vert body height
• Angulation of thoracolumbar junct > 20 deg
• Mutiple adjacent column of spine
• Failure of 2/3 of column of spine

Chance fracture
• Anterior column falls in tension (along w/ the
middle and posterior columns)
• Three columns rupture in distraction (tension)
• Seldom assc w/ neurologic comprimise unless
• Unstable

Burst fracture • Compressive failure of vert body both anteriorly & posteriorly . w/ failure of both anterior & middle columns • Axial loading applied to intravertebral disc results in increased nuclear pressure and hoop stresses in the annulus .

Burst frx location
• Cervical burst fix
• Lumbar burst fix
• Thoracic burst fix
• Thoracolumbar burst fix

Classification :
• Stable frx
- neurologically intact
- poterior arch remains intact : pedicl
widening implies post arch disruption
- less than 50% anterior body height
- compression fracture

• Unstable frx
- neurologic defisit
- loss of 50% vertebral body height
- fracture dislocation
- thoracolumbar burst frx

and may occur w/ minimal trauma/ .anterior synchondroses fuses at age 7 .posterior synchondroses fuses at age 4 . Jefferson Fracture • Pediatric frx .frx proceeds thru open synchondroses.

causing a posterior arch fracture .may also be caused by hyperextension.original description in 1920 noted role of axial compression .• Mechanism .

low rate of neurologic deficits is due to large breadth of C1 canal .• Associated injuries .approx 50% chance that some other C-spine injury is present .approx 1/3 of these fractures are associated with a axis fracture .

Radiographs • Odontoid view • Lateral view • Flexion and extension views • CT scan .

dens occupies a 1/3 and the remaining 1/3 is empty • Mechanism – Flexion loading – Extension loading . Dens Fracture • Odontoid fractures are the most common upper cervical spine fratures • Remember rule of thirds – cervical cord occupies a 1/3 of canal.

Classification • Type I • Type 2 Dens frx • Type 3 .

Associated Injury • Atlas frx • Transverse ligament rupture • Pharangeal injury .

because mechanism of injury for clinically encountered frx often lacks large traction force present in judicial hangings . Hangman’s frx/Traumatic Spondylolisthesis of the Axis • Fix of pars interarticularis of C2 & disruption of C2-C3 junction • Type of traumatic spondylolisthesis – Hangman’s frx • Term Hangman’s fracture is not accurate for the majority of cases.

• In cases in which there is neurologic injury. there will usually be significant horizontal translation w/ accompanying damage to the posterior longitudinal ligament w/ or w/o damage of the C2 – C3 interspace .

• Mechanism of injury in adults – Judical lesion : hyperextension and distraction – Hyperextension w/ vertical compression of posterior column. but other causes include flexion of flexed neck & compression of an extended neck – A blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles of C2 known as traumatic spondyloslishthesis of C2 . & translation of C2 and C3 – Forceful extension of already extended neck is most commonly described mech of injury.

SCIWORA Syndrome • Occurs may often in pediatric population • Accounts for up to 2/3 of severe cervical injuries in children < 8 years of age • Inherent elasticity in pediatric cervical spine can allow severe spinal cord injury to occur in absence of x-ray findings .

Clasification spinal cord injury • Complete • Incomplete • Anterior cord syndrome • Central cord syndrome • Brown sequad • Cauda equina .

Anatomy crossection spinal cord Ascending Tract Tracts of Goll and Burdach Proprioception.vibration.discr uncrosssed (fasc gracilis and cuneatus imination Dorsal and ventral Proprioception. temperature crossed Spinal olivary tract Tendon and muscle crossed proprioception Ventral spinothalamic tract Deep tactile and pressure crossed sensation Descending Tract Lateral corticospinal tract Motor control uncrossed (pyramidal) Rubrospinal tract Cerebellar reflexes crossed Lateral reticulospinal tract Inhibits locomotor conytrol crossed Reticulospinal tract Facilittes locomotor control uncrossed Vestibulospinal tract Postural control Uncrossed Tectospinal tract Eye and ear reflleces crossed . light touch uncrossed spinocerebellar tract Lateral spinothalamic tract Pain.

Complete / incomplete Spinal Cord Lession • Complete cord injury : there is complete loss of sensation and muscle function in the body below the level of the injury • An injury to the upper portion of the spinal cord in the neck can cause quadriplegia-paralysis of both arms and both legs. . If the injury to the spinal cord occurs lower in the back it can cause paraplegia- paralysis of both legs only.

• Present when there is any distal sparing of motor or sensory function along with sparing of perirectal sensation . In most cases both sides of the body are affected equally.• Incomplete lesion : there is some remaining function below the level of the injury.

• Diff dx of incomplete lesions – Central cord syndrome – Brown sequard syndrome – Anterior cord syndrome – Posterior cord syndrome – Isolated nerve root injury – Cauda equina syndrome (w/ or w/o root escape) – Conus medullaris injury .

Anterior Cord Syndrome • Damage is primarily in the anterior 2/3 of cord and is related to vascular insuffiency • There is sparing the posterior columns • Syndrome is manisfested by complete motor paralysis (corticospinal func) and sensory anesthesi (spinothalamic func) • Patient demonstrates greater motor loss in the legs than arms .

Prognosis • anterior cord syndrome has the worst prognosis of all cord syndromes • prognosis is good if recovery is evident & progressive during first 24 hours • after 24 hrs. . prognosis for further functional recovery are poor. if no signs of sacral sensibility to pinprick or temp are present. only 10 to 15% of patients demonstrate functional recovery.

. Central Cord Syndrome • most common incomplete cord lesion • frequently associated w/ extension injury to osteoarthritic spine (cervical spondylosis) in middle aged person who sustains hyperextension injury • cord is injured in central gray matter. & results in proportionally greater loss of motor function to upper extremities than lower extremities w/ variable sensory sparing.

Anatomy: • fibers responsible for lower extremity motor and sensory functions are located in the most peripheral part of the cord • whereas fibers controlling the upper extremity and voluntary bowel and bladder function are more centrally located • sacral tracts are positioned on the periphery of the cord & are usually spared from injury. .

Mechanism of Injury: • hyperextension injury • central cord injury and hemorrhage occur with compression of adjacent white-matter tracts • more peripheral positioning of lower extremity axons within the spinal cord tracts accounts for the injury pattern .

• damage to central portion of corticospinal and spinothalamic long tracts in white matter produces upper motor neuron spastic paralysis of trunk and lower extremity .

Examination • central cord syndrome is remarkable for more cord involvement in the upper extremities than in the lower extremities • manifests w/ loss of distal upper extremity pain & temperature sensation and strength. w/ relative preservation of lower extremity strength & sensation .

.upper extremities:  mixed upper and lower-motor-neuron lesion. w/ partial flaccid paralysis of upper extremities (indicative of involvement of lower motor neurons) prognosis is variable w/ poor hand function lower extremities:  spastic paralysis of lower extremities (indicative of involvement of upper motor neurons)  bladder and bowel function may also be lossed.

Brown Sequard Syndrome • type of incomplete cord syndrome • injury to either side of spinal cord produces ipsilateral muscle paralysis (from corticospinal tract injury) and contralateral hypersthesia to pain and temperature (from spinothalamic injury) .

.• syndrome results from hemitransection of spinal cord w/ unilateral damage to the spinothalamic & corticospinal tracts and resultant loss of ipsilateral motor & dorsal column function & of contralateral pain and temperature sensation • often due to penetrating trauma or unilateral facet fracture or dislocation.

Prognosis: • this syndrome has a good prognosis for recovery • more than 90% of pts regain bladder & bowel control & ability to walk • most patients will regain some strength in lower extremities and most will regain functional walking ability. ..

rectal tone. . the caudal equina may sustain considerable initial trauma • in any potential cauda equina syndrome it is important to examine for saddle anesthesia. Cauda Equina Syndrome • urinary retention is the most consistent finding • in spinal cord injuries. and sacral sparing. bulbocaverosus reflex.

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Further flexion increases neurological injury . Significance • Unstable if middle column + either Anterior or Posterior column is damaged • Rupture of interspinous ligament is : .associated with avulsion of spinous process .Unstable spine .

Level of Spinal injury • Neurological level is at the most lowest segment with normal motor & sensory function • Difficult to determine : .as most muscle efferents receive fibres from more than one level .Dermatomes have imprecise boundaries.Closed cord lesions may extend over several cms. . .

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