1 / 151

SPINAL CORD INJURIES

SPINAL CORD INJURIES. M.R.EHSAEI M.D ASSOCIATE PROFESSOR OF NEUROSURGERY. Anatomy of spine. Complete spine contains 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal Spinal cord protection Ligaments. Ligaments of spine. Vertebra (29) 7 cervical, 12 thoracic,

Download Presentation

SPINAL CORD INJURIES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. SPINAL CORD INJURIES M.R.EHSAEI M.D ASSOCIATE PROFESSOR OF NEUROSURGERY

  2. Anatomy of spine • Complete spine contains • 7 cervical • 12 thoracic • 5 lumbar • 5 sacral • 4 coccygeal • Spinal cord protection • Ligaments

  3. Ligaments of spine

  4. Vertebra (29) 7 cervical, 12 thoracic, 5 lumbar, 5 sacral Conus medullaris at L1-2 vertebrae 31 spinal cord segments 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal C1 dorsal roots missing in some

  5. Cerebrospinal fluid Clear 50-200 mm H2O pressure 0-10 WBC 0 RBC < 45 mg/100 ml protein glucose 2/3 blood level 50-80 mg/100 ml Spinal tap done at L3-L4 Dural sac ends at vert. S1-S2

  6. Cervical Spine • C1 – Atlas • C2 – Axis • Vertebral canal – space for spinal cord • Intervertebral foramen – nerves exit from canal

  7. Anatomy of spine • Anterior column • Half of Vertebral bodies and intervertebral disc • Anterior longitudinal ligament • Middle column • Half of Vertebral bodies and intervertebral disc • posterior longitudinal ligament • Posterior column • Pedicles, facet joints, lamina • Supraspnious, interspinous, infraspinous ligaments

  8. SPINAL CORD INJURIES Car Crashes: 83% Motorcycle incidents: 10% Bicycle accidents: 3% Medical/Surgical Complications: 38% Hit by falling Object: 30% Pedestrian: 22% Gunshot: 92% Personal Contact: 6% Diving: 55% Snow skiing: 8% Surfing: 6% Source: National Spinal Cord Injury Statistical Center

  9. Epidemiology • Spinal injury • Motor vehicle crashes :41% • Falling down :21% • Sporting activity:8% • Human violence:22% • Others:8% • Average age : 34yrs • M:F = 4:1

  10. Epidemiology • Approx. 100,000 new cases/year, 80% male. Age group most commonly injured: 16-30 years (43%) and 31-45 (28%). • Although Vehicle is the leading cause overall, Falls become the leading cause in people over 60 years.

  11. Spinal Cord Injuries • Traumatic injury of vertebral and neural tissues due to compressing, pulling or shearing forces • Most common locations: cervical (1&2), cervical (4-7), and 12th thoracic – 2nd lumbar vertebrae • Locations reflect most mobile portions of vertebral column and the locations where the spinal cord occupies most the the vertebral canal

  12. Spinal Cord Injuries • Vertebral injury can occur due to fracture, dislocation, or both. • Within minutes after injury, hemorrhages appear in the central gray matter, pia, and arachnoid. • Local hemorrhages reduce vascular perfusion

  13. Spinal Cord Injuries

  14. General Symptoms & Signs : • Pain &Tenderness • Skin abrasions or contusions • Subcutaneous Hematoma • Muscle Spasm • Cripitation in Touch • SpinalDeformity

  15. Neurological Exam: • Detection & Documentation : • Sensory Level • Posterior Column function • Sacral Sensory Sparing • Muscle Weakness (0 - 5 ) • Pathological Reflex (BCR & Babinski) • Rectal Exam for Tone & cotracture

  16. Neurological evaluation: • Complete inj.:no motor or sensory function below the zone of inj. • Incomplete inj.:partial preservation of motor or sensory function below the zone of inj.

  17. Neurological evaluation:cervical inj. • Incomplete inj.: • Ant cord syn. • Central cord syn. • Brown-sequard syn. • Post.cord syn. • Spinal shock: • hypotension without tachycardia (motor,sensory,and reflexes are absent but cannot determine complete inj.until bulbocavernosus or other reflexes return within 24 houres.)

  18. Incomplete Spinal Cord Lesions • The anterior cord syndrome • cervical flexion injuries causing cord contusion • protrusion of a bony fragment or herniated intervertebral disk into the spinal canal • laceration or thrombosis of the anterior spinal artery • rarely, systemic embolization or prolonged cross-clamping of the aorta during resuscitation or surgery

  19. Incomplete Spinal Cord Lesions • central cord syndrome (m/c) • affects the central gray matter and the most central portions of the pyramidal and spinothalamic tracts • a greater neurologic deficit in the upper extremities than in the lower extremities

  20. Incomplete Spinal Cord Lesions • The Brown-Séquard syndrome, or hemisection of the spinal cord • a penetrating lesion such as a gunshot or knife wound • ipsilateral motor paralysis and contralateral sensory hypesthesia distal to the level of injury

  21. Neurologic status : frankel scale • a) no motor or sensory function • b) sensation but no motor function • c) motor function present but useless • d) motor function present but useful • e) normal motor and sensory

  22. Neurologic exam: cervical inj. • C4(spont.breathing),C5(deltoids and biceps) C6(wrist ext.),C7(triceps and wrist ext.),C8 (finger flex.),T1(intrinsics). • Sensory:C5(upper outer arm),C6(thumb),C7 (long finger),C8(little finger),T1(medial forearm).

  23. Prognosis of spinal cord inj.: • Complete inj: usually remains complete,but one or two level recovery is expected. • Incomplete inj.:have potential for significan t recovery, particlarly in bronwn-sequard and central cord syn.

  24. Prognosis of spinal cord inj.: • Gunshot wound to the spine with spinal cord inj.carry a poor prognosis for recovery. • Spinal cord recovery is better if bony impingment is removed for incomplete type. • Patients with congenital C1-C2 instability and congenital stenosis have higher incidence of spinal cord inj.

  25. Prognosis of spinal cord inj.: • Patient with ankylosing spondylitis often sustain unstable three-column inj.,even with minor trauma. • High dose corticosteroid is administrated early to patient within 8 hours of inj. to improve the prognosis.

  26. RADIOLOGICAL studies: • Plain x-ray: Ap--LAT--Open mouth—Oblique- Pillar view--Stretch test--Flexion/Extension view • Tomography • C.T scan :best modality for bony lesion. • Myelography • C.T myelography • M.R.I: best for soft tissue and give prognosis after inj.

  27. Upper cervical inj. • occipital condylar fx. • occiput-c1 dislocation. • C1-C2 subluxation. • fracture of C1. • frature of odontoid. • fracture through the pedicle of C2.

  28. Occipital condylar fx. • diagnosis with tomogram or C.T scan. • lig.inj, I.c.hematoma,and neurological deficit may accompany this inj. • treatment: • usually rigid orthosis or halo vest for 3 m. • flex/ext film is obtained at 3 m. • occiput to c2 fusion if resultant instability.

  29. occiput-c1 dislocation: # flex/ext force on the head. #disruption of all lig. #unstable and always fatal. #treatment:occiput-c1 fusion.

  30. C1-C2 subluxation: • Rupture of transverse lig. • Atlantodens interval: • 3-5mm indicate rupture of transverse lig. • >7-8mm indicate all lig.disruption. • >10mm causes spinal cord compression. • Treatment: • if instability 3-5mm==>halo for 2-3 m then dynamic study repeated.if instability >4mm then needs fusion c1-c2. • if instability >5mm then early fusion c1-c2.

  31. C1-C2 subluxation: • Atlantoaxial rotatory fixation: the head is tilted toward the side of fixation and the chin and c2 spinous process is pointed toward the opposite direction. • Type 1: rotatory fixation with no ant. displacement. • Type 2: rotatory fixation with 3-5mmant.displacem. • type3: rotatory fixation with>5mm ant displacement • Type4:rotatory fixation with post.displacement. • tratment: reduction&c1-c2 fusion if unstable.

  32. Stable Upper cervical Injuries: • Atlas fractures: • ant. arch fx. • post. arch fx. • lat. mass fx.with less displacement. • Axis fractures: • type 1 odontoid fx. • hangman fx.without angulation.

  33. Fracture of C1: • Axial loading usually with breaks at two sites. • >7mm widening of lat.mass==>trnsverse lig.rupture .==>first immobilization with hallo for 2-3m and C1-C2 fusion may be performed if instability is greater than 5mm.

  34. Fractures of odontoid: • Type 1:rare,avulsion fracture of the tip. stable and treatment is cervical collar. • type 2: fracture at the base of the odontoid. • ant .displ.(flex.inj.) is more common than post displ.(ext.inj.). • nonunion rate is 20-80% especially age >50 y. • Type 3:fracture through the body. • nondisplaced: cervical orthosis or halo. • displaced: halo jacked for 3m.

  35. ODONTOID FX FIXATION OF ODONTOID

  36. Fractures through pedicle of C2: • Mechanism of Hangman fracture :ext.inj. • Types: • type 1: minimal displacement(less than 3mm) • type 2: significant displacement (>3mm) and angulation(>11 deg.) • type 2A: minimal displacement(<3mm) and angulation(>11 deg.) • type 3: associated facet dislocation.

  37. Fractures through pedicle of C2: • Treatment: • type 1: halo jacket for 12 w. • type 2:traction for 2-3w for reduction +halo for 10-12w. • type 2A: no traction,extention,and compression,halo for 3m. • type 3 or late instability or nonunion: ant.C2-C3 fusion or post pedicular screw fixation(C2-C3 plating.

  38. M.R.I of cervical At C4-C5 , Disruption and Widening of the intervertebral Disc, compression fracture of C5, anterolisthesis of C4-C5

  39. Facet fracture/dislocation: • UNILATERAL OR BILATERAL. • MAY BE WITH DISC HER. & CORD COMP. • IN UNILATERAL :DISPLACEMENT IS ABOUT 25% • IN BILATERAL :DISPLACEMENT IS ABOUT 50 %.

More Related