TRAUMA OF SPINE SPINAL CORD

1. TRAUMA OF SPINE & SPINAL CORD Dr K. Bougoulias Orthopaedic & Trauma surgeon MSc Sports & Exercise Medicine Diploma Orth and Trauma

2. Objectives Incidence Anatomy Pathophysiology Classification Accident scene management Resuscitation Assessment Intervention

3. Incidence 4.0 to 5.3 per 100.000 population � 12000 new spinal cord inj per year ( Thurman et al, paraplegia 1994) Neurological deficits 10 to 25% with 40% in cervical spine and 20% thoracolumbar spine

4. Incidence Motor vehicle accidents 45% Falls 20% Sports 15% Acts of violence 15% Other 5%

6. Anatomy 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral,4 coccygeal Ligaments Intervertebral disc-nerve roots Lordosis- cyphosis 50% flexion � extension C1 �occiput 50% rotation C1-C2

12. Topographic Landmarks Mandible Hyoid cartilage Thyroid cartilage Cricoid cartilage Vertebra prominence Scapular spine Distal tip of scapula Iliac crest C2-3 C3 C4-5 C6 C7 T3 T7 L4-5

14. Spinal cord Extends from brain stem to inferior border L1- Conus Medullaris-Cauda Equina Dorsal columns: deep touch, proprioception, vibration Lateral spinothalamic tract: pain, temperature Lateral corticospinal tract: voluntary contraction Anterior spinothalamic tract: light touch Anterior corticospinal tract: voluntary contraction.

17. Pathophysiology Kinetic injury is transferred by one of two mechanisms : Direct : flexion , extension, rotation Indirect: impaction of bone or disc fragments

18. Pathophysiology Contusion and compression rather complete transection Cord injury leads to petechial haemorrhages, myelin sheath and axoplasm disruption, edema within 6 hours, tissue hypoxia, cystic degeneration (Ducker et al, J neurosurgery, 1971)

19. Classification Definitions by ASIA: Complete injury �No motor and/or sensory function exists more than three segments below the level of injury Incomplete injury: some neurological function exists Level of injury: The most caudal segment that tests intact (motor and sensory)

20. Simplicity(Waters et al, 1991, Paraplegia) Sacral nerve root sparing indicates at least partial structural continuity Sacral sparing is diagnosed by: Periannal sensation, rectal tone function, great toe flexion

21. Complete injury Spinal shock for 24 hours, if more ,no functional recovery in 99% of patients (Stauffer 1975, Clin Orthopaedics) * Exception: injury to conus medullaris

22. Incomplete Spinal cord Injury Syndromes Central cord Syndrome: most common, quadriplegic with periannal sensation, early return of bladder & bowel function, 75% recovery Anterior Cord Syndrome: Complete motor and sensory loss- retained trunk and lower extremity deep pressure and proprioception- worst prognosis ( 10%)

23. Incomplete Spinal cord injury syndromes Posterior cord syndrome: Rare, loss of deep pressure, deep pain, proprioception � normal cord function otherwise Brown- Sequard: unilateral cord injury, ipsilateral motor deficit, contralateral pain and temperature hypesthesia � best prognosis >90%

25. Accident Scene Management ATLS ABCD (Airway- Breathing- Circulation, C spine- Disability, neurological status) High level of suspicion Trauma patient is considered that has spine injury until prove otherwise

30. Basic rules C spine secured before move from accident scene Sandbags on either side of head which is taped to backboard Full length backboard Repeat ABCD Transport

31. High level of suspicion Frequently poly-trauma patients Facial injury � C spine ? Thoracic & abdominal � Thoracolumbar Spine

32. Neurogenic shock Hypotension with bradycardia due to disruption of sympathetic outflow and unopposed vagal tone ( Grundy et al, 1986) Zipnic et al ( J. Trauma 1993) showed that penetrating trauma differs from blunt trauma Out of 75 patients only 7% developed neurogenic shock

33. Resuscitation No matter cause of hypotension, support of blood loss needs aggressive treatment by blood & volume replacement. Vasopressors if hypotension without tachycardia persists Leg elevation to counteract venous pooling in extremities Atropine? maintain heart rate ? Gentle sympathomimetic agent ( e.g phenylephrine

34. Assesment Secondary survay ABCDE Xrays Intubation always with a jaw thrust manuever Responsive patient: Past history, location pain, sensation (marked on skin), motor function, Reflexes

35. Unconscious patient Observation of spontaneous extremity motion Spontaneous respiration indicate normal thoracic innervation Log roll: ecchymosis, abrasions (location), step off, interspinus widening

43. Reflexes Spinal shock: absent reflexes for 24h replaced by hyper-reflexia, muscle spasticity, clonus Spinal injury- concomitant head injury Extremity reflexes without spontaneous motion = cranial upper motor neuron lesion Absence of reflexes = lower motor neuron lesion

44. Reflexes Babinski sign & Oppenheim�s sign = upper motor neuron lesion Cremasteric reflex T12-L1 Annal wink S2, S3, S4 Bulbocavernosus reflex S3, S4

47. INTERVANTION Pharmacological High doses of intravenous methylprednisolone? Bracken et al (1990, 1991), controlled, randomized study: MPS within first 8 hours improved neurologic recovery at 1 year Naloxone no better than control MPS after 8h, patient less function than placebo

48. Intervention 30mg/ Kg body weight bolus Continuous infusion 5,4 mg/Kg/hr for 23h The earlier the administration the better the outcome More literature: Kwon BK et al, 2004 Wellman et al, 2003 Bledsoe BE et al, 2004

49. Physical Intervention Immobilization Reduction Stabilization

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