Spine Injury

1. Spine Injury Spine injury: 2-5/100000/yr Medullary injury: 10% of the cases Traffic accident, water sport injury, ski accident

2. General considerations Even more specialized requirements Guidelines are contradictory Individual decision Second spine injury occurs in 20 % Simultaneous injury, i.e.chest, arterial dissection etc. Less than 5 % of the cases are children Frequency in order Cervical Thoracic Lumbar

3. Injury Spine Distorsion: transient vertebral dislocation during the impact disco-ligamenter instability may result neurol. deficit Subluxation partial dislocation minor shift of facets result instability Luxation dislocation complete shift of facets result instability Fracture subluxation & luxation rarely occur without fracture Medulla/Root Incomplete any residual function 3 segments below the level of injury Types central cord sy Brown-Sequard sy anterior cord sy posterior cord sy Complete no preservation of any function, beyond 24 hours spinal shock Traumatic root injury

4. Whiplash-Associated Disorder (WAD) Most common Usually not associated with fracture/dislocation Due to hyperflexion/hyperextension Symptoms/grades no complaints,no sign + reduced motion, tenderness + weakness, sensory deficit,absent reflexes + fracture, disclocation Treatment Cervical soft collar, passive modality physiotherapy, NSAIDs, non-narcotic analgesics

5. Injury Spine Distorsion: transient vertebral dislocation during the impact disco-ligamenter instability may result neurol. deficit Subluxation partial dislocation minor shift of facets result instability Luxation dislocation complete shift of facets result instability Fracture subluxation & luxation rarely occur without fracture Medulla/Root Incomplete any residual function 3 segments below the level of injury Types central cord sy Brown-Sequard sy anterior cord sy posterior cord sy Complete no preservation of any function, beyond 24 hours spinal shock Traumatic root injury

6. Surgical indications Reposition Fixation-stabilization Stability ? three column theory by Denis any two columns injury Decompression dislocation bony fragments haematoma Contusion swelling

7. Pathomechanisms of spinal fracture related to the impact Axial – compression fracture Hyperflexion – compression, tensile Hyperextension – compression, tensile Shearing– perpendicular to the spinal axis Hyperrotation Whiplash – hyperflexion followed by hyperextension

8. Fracture types linear vertebral body, arch, spinal process tear drop compression burst fracture dislocation, luxation complete burst, with possible rotation, /chance fracture) luxation without fracture

14. Different pathomechanisms of medulla injury Commotion improving in 6 hour, complete recovery within 24-48 hours Contusion oedema, haemorrhagy, infarct Bleeding Intra, extramedullary, extradural (i.e.epidural) Tear /split) of medulla, or roots Partial or complete (regeneration related to myelin sheath continuity)

15. Diagnostics X-ray whole spine, lateral, ap, and special direction, i.e. transoral, Towne view, fluoroscopy to check stability CT Reconstruction, 3D view, CI-ThI !!! MR, myelo-CT

18. Goals of surgery Decompression laminectomy, haematoma evacuation, removal of bony fragments, anterior decompression, corpectomy Reposition Crutchfield extension during surgery under anaesthesia and relaxation Stabilisation surgical fusion, wiring, different instrumentation vertebroplasty External support Cervical bracing Soft sponge collar Philadelphia collar Halo-vest brace

21. Steroid in spinal injury NASCIS I - the change in motor function in specific muscles and changes in light touch and pinprick sensation no benefit from methylprednisolone, but the dose was considered to be low NASCIS II used a much higher dose - post hoc analyses detected a small gain in subgroup of patients within 8 hours after their injury NASCISIII, Japanese Study and metaanalysis no benefit incidence of sepsis and pneumonia, hyperglycaemia, gastrointestinal complications was higher is not a standard treatment nor a guideline for treatment but, rather, a treatment option, for which there is very weak level II and III evidence.

22. Peripheral nerve injury Result loss of motor, sensory function (causalgia) or both 2-3% of trauma patients Injury Trauma (blunt, penetrating) Acute compression Consequence of nerve injury Demyelination Axonal degeneration Any of them results loss of function Recovery Remyelination Axonal regeneration Reinnervation of receptors, muscles, end plates

23. Classification of nerve injury (Seddon) Neurapraxia temporary conduction block demyelination of the nerve at the site of injury electrodiagnostic study results are normal no denervation muscle changes no Tinel sign complete recovery may take up to 12 weeks Axonotmesis wallerian degeneration distal to the level of injury and proximal axonal degeneration to at least the next node of Ranvier, or even beyond electrodiagnostic studies: denervation changes and in cases of reinnervation, motor unit potentials (MUPs) axonal regeneration rate : 1 mm/d or 1 in/mo, can be monitored with an advancing Tinel sign endoneurial tubes remain intact, recovery is complete not intact, mixed reinnervation, incomplete recovery Neurotmesis complete transsection, or scar formation preclude axonal cure electrodiagnostic studies: denervation changes and no MUPs are present Tinel sign is noted, but it does not advance beyond no improvement in function requires surgery to restore neural continuity, thus permitting axonal regeneration and motor and sensory reinnervation

24. Indications for nerve injury surgery In case of closed nerve injury no evidence of recovery either clinically or with electrodiagnostic studies at 3 months following injury In case of open nerve injury (ie, laceration) all lacerations with a reported loss of sensation or motor weakness should be surgically explored as soon as possible the distal nerve, when it is separated from the proximal nerve, can still be stimulated for up to 72 hours afterwards. This allows us to identify which components of the nerve are intact and which are damaged, helps proper reconstrucion Crush nerve injury Surgical exploration of the nerve may be delayed for as long as several weeks after 3 months with no evidence of reinnervation electrically (motor unit potentials [MUPs] present) or clinically, surgical reconstruction with repair or graft is indicated

25. Nerve fiber myelinated axons, surrounded by the endoneurium (connective tissue) Groups of nerve fibers are surrounded by the perineurium to form fascicles Groups of fascicles are surrounded by the internal and external epineurium

26. Diagnostics electromyography (EMG) nerve conduction studies innovative EMG techniques advanced MRI ultrasound intraoperative neurophysiology about 1 month after the injury and repeat them every 4-6 weeks until surgical decision (closed injury)

27. Nerve repair surgery has changed during the last decade previous strategy was to put the nerve together to look as normal as possible but it can often redirect axons into the wrong distribution present strategy has now changed to deciding which are the most important targets and transferring or grafting nerves into the targets that are the most important to be reconstructed peel off the most important nerve components transfer into this from neighbouring intact nerve distribution reconstruct the rest of the injured nerve Summerizing: to target specific critical functions and then graft to the remainder to get the best results

28. i.e. In an upper brachial plexus injury oftentimes when the shoulder and biceps innervation is missing, it is advised to completely ignore the injury site and to go with distal transfers from the healthy triceps to the deltoid, from healthy median ulnar nerve to the biceps It is very important to remember that patients who have these injuries should get to a surgeon who can treat them as early as possible -- within the first month is ideal