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    Trauma Saraf Spinal

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    Fatahillah Nazar
    Spinal cord ends at L1 Three tracts can be assessed clinically. Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury - If any motor or sensory function remains, prognosis for recovery is much better.

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    Trauma Saraf Spinal

    Uploaded by

    Fatahillah Nazar
    64 views41 pages
    Spinal cord ends at L1 Three tracts can be assessed clinically. Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury - If any motor or sensory function remains, prognosis for recovery is much better.

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    Spinal cord ends at L1 Three tracts can be assessed clinically. Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury - If any motor or sensory function remains, prognosis for recovery is much better.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views41 pages

    Trauma Saraf Spinal

    Uploaded by

    Fatahillah Nazar
    Spinal cord ends at L1 Three tracts can be assessed clinically. Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury - If any motor or sensory function remains, prognosis for recovery is much better.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 41

    TRAUMA SARAF SPINAL

    Wiryawan Manusubroto SpB,SpBS(K) SMF Bedah Saraf RSUP dr Sardjito

    INTRODUCTION

    ANATOMY PHYSIOLOGY
    Spinal cord ends at L1 Three tracts can be readily assessed clinically. - The corticospinal tract - The spinothalamic tract - The posterior columns Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury: If any motor or sensory function remains, prognosis for recovery is much better.

    Thoracic and lumbar levels supply sympathetic nervous system fibers Cervical and sacral levels supply parasympathetic nervous system fibers

    Dermatomes and Myotome

    PATHOLOGY OF SCI
    Primary Injury
    occurs at the time of injury may result in
    cord compression direct cord injury interruption in cord blood supply

    Secondary Injury
    occurs after initial injury may result from
    swelling/inflammation ischemia movement of body fragments

    Cord transection
    Complete
    all tracts disrupted cord mediated functions below transection are permanently lost determined ~ 24 hours post injury possible results quadriplegia paraplegia

    CLINICAL CLASSIFICATION

    Cord transection
    Complete
    all tracts disrupted cord mediated functions below transection are permanently lost determined ~ 24 hours post injury possible results quadriplegia paraplegia

    Cord transection
    Incomplete
    some tracts and cord mediated functions remain intact potential for recovery of function Possible syndromes Brown-Sequard Syndrome Anterior Cord Syndrome Central Cord Syndrome

    Incomplete Cord Injury


    Injury to one side of the cord (Hemisection) Often due to penetrating injury or vertebral dislocation Complete damage to all spinal tracts on affected side Prognosis for recovery is variable

    Brown Sequard Syndrome

    Exam Findings
    Ipsilateral loss of motor function motion, position, vibration, and light touch Contralateral loss of sensation to pain and temperature Bladder and bowel dysfunction (usually short term)

    Brown Sequard Syndrome

    Anterior Spinal Artery Syndrome


    Supplies the anterior 2/3 of the spinal cord to the upper thoracic region caused by bony fragments or pressure on spinal arteries

    Anterior Cord Syndrome

    Exam Findings
    Variable loss of motor function and sensitivity to pinprick and temperature loss of motor function and sensation to pain, temperature and light touch Proprioception (position sense) and vibration are preserved

    Anterior Cord Syndrome

    Usually occurs with a hyperextension of the cervical region Exam Findings


    weakness or paresthesias in upper extremities but normal strength in lower extremities varying degree of bladder dysfunction

    Central Cord Syndrome

    Injury to nerves within the spinal cord as they exit the lumbar and sacral regions
    Usually fractures below L2 Specific dysfunction depends on level of injury

    Exam Findings
    Flaccid-type paralysis of lower body Bladder and bowel impairment

    Cauda Equina Syndrome

    Temporary loss of autonomic function of the cord


    at the level of injury Usually results from cervical or high thoracic injury Effects may be temporary and resolve in hours to weeks Presentation Flaccid paralysis distal to injury site Loss of autonomic function hypotension or relative hypotension vasodilation loss of bladder and bowel control priapism loss of thermoregulation warm, pink, dry below injury site relative bradycardia

    Neurogenic Shock

    Effect on other Organ Systems


    Hypoventilation due to the paralysis:
    Intercostal muscles Diaphragm

    The inability to perceive pain may mask a potentially serious injury elsewhere:
    Abdominal injury no abdominal tenderness Lower extremity injury

    Compression Flexion Extension Rotation Lateral bending Distraction Penetration Rearback - Fall > 10 feet

    Mechanism Of Injury ( High Energy )

    ABCs
    Airway and/or Breathing
    Inability to maintain airway Apnea Diaphragmatic breathing Cardiovascular impairment Shock Hypotension and or bradycardia Patient appears warm and dry Hypoperfusion Level of consciousness

    GENERAL ASSESMENT

    Inspection and palpation: Occiput to Coccyx


    Tenderness to the vertebrae Gap or Step-off (both very rare) Edema and bruising Spasm of associated muscles

    Neurological assessment
    Motor Sensation Reflexes

    CLINICAL EVALUATION

    NEXUS Criteria: 1. Absence of tenderness in the posterior midline 2. Absence of a neurological deficit 3. Normal level of alertness (GCS score = 15) 4. No evidence of intoxication (drugs or alcohol) 5. No distracting injury/pain

    NEXUS

    Any patient who fulfilled all 5 of the criteria were considered low risk for Cspine injury and as such did not need C-spine radiography For patients who had any of the 5 criteria, radiographic imaging was indicated in the form of AP, lateral, and odontoid Cspine views

    NEXUS

    Imaging Options
    Initial Screening Options:
    Plain films Lateral, AP, and Odontoid, Optional: Oblique and Swimmers (if necessary) CT- much better than plain films for bony fractures/dislocations. Poor evaluation of ligamentous injuries.

    Other cervical spine imaging options


    MRI- Very good for soft tissue/ligamentous injuries. Flexion-Extension Plain Films- to determine stability (may replace MRI if unavailable or contraindicated)

    AP/LATERAL/SPECIAL VIEW
    Anterior subluxation of one vertebra on another indicates facet dislocation Less than 50% of the width of a vertebral body implies unifacet dislocation Greater than 50% implies bilateral facet dislocation This is usually accompanied by widening of the interspinous and interlaminar spaces

    X-ray Guidelines (cervical) Mnemonic AABBCDS Adequacy, Alignment Bone abnormality, Base of skull Cartilage, Disc space Soft tissue

    Radiological Evaluation

    Thin cut CT scanning should be used to evaluate abnormal, suspicious or poorly visualized areas on plain radiology The combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%

    CT Scanning

    Ideally all patients with an abnormal neurological examination should be evaluated with an MRI scan Patients who report transient neurological symptoms but who have a normal exam should also undergo an MRI assessment of their spinal cord

    MRI

    Spinal injuries can be described as, Fractures Fracture dislocations SCIWORA Penetrating injuries Injuries can be stable or unstable All patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury until proven otherwise.

    Morphology

    Stable vs Unstable Fractures


    Stability of cervical spine is provided by two functional vertical columns
    Anterior column: vertebral bodies, the disc spaces, the anterior and posterior longitudinal ligaments and annulus fibrosus Posterior column: pedicles, facets and apophyseal joints, laminar spinous processes and the posterior ligament complex

    As long as one column is intact the injury is stable.

    Primary Goal
    Prevent secondary injury

    Stabilization of the spine begins in the initial assessment


    Treat the spine as a long bone
    Secure joint above and below

    Caution with partial spine splinting

    Immobilization vs Motion Restriction

    MANAGEMENT OF CORD

    General Precaution
    Spinal Motion Restriction: immobilization devices ABCs
    Increase FiO2 Assist ventilations as needed with cervical spine control Indications for intubation:acute respiratory failure, Glasgow score <9, increased respiratory rate with hypoxia, PCO2 more than 50, and vital capacity less than 10 mL/kg IV Access & fluids titrated to BP ~ 90-100 mm Hg

    Look for other injuries: Life over Limb Transport to appropriate SCI center once stabilized

    Consider High Dose methylprednisolone:


    30 mg/kg bolus over 15 mins After bolus: infusion 5.4mg/kg IV for 23 hours Controversial as recent evidence questions benefit Must be started < 8 hours of injury Most spine surgeons do not use for penetrating trauma

    TRAUMA : MECHANISM ? ABC AND D PEX

    UNCONSIOUSNE SS ALERT ( NEED ICU/INTUBATED)

    D
    SSX+

    CARDINAL SSXNO NEED IMAGING

    (IF PLEGIA , DISTINCT FROM SPINAL SHOCK)

    SSX

    IS UNCLEAR CLARIFY !

    FLOWCHART 1

    SSX+ (>+1)

    IMAGING AP,LAT,SPESIFIC PLAIN X RAY

    PLAIN X RAY NEGATIF

    PLAIN X RAY POSITIF

    C
    STABEL UNSTABEL

    VASCULAR PROBLEM ?

    CLEARENCE BY EXPERT /CT/MRI

    FLOW CHART B

    STABEL
    IS DECOMPRESSION NEEDED

    UNSTABEL

    STABILIZING

    STABILIZING IS PURSUIT DEPEND ON LAST CONDITION OF STABILITY

    DECOMPRESSION IF NEEDED

    FLOWCHART C

    ENTIRE SPINAL EVALUATION AP/LAT CERVICAL 3 D CT CERVICAL-THORACAL AP/LAT THORACOLUMBAR

    FLOWCHART D

    Points to Remember:
    Maintain cervical spine immobilization until spine properly evaluated Criteria exist (NEXUS ) that identify the need for cervical spine imaging
    Patients negative for either criteria may have their spine clinically cleared

    Screen patients with plain radiograph or CT


    CT better than plain radiographs

    MATUR NUWUN

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