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Spinal injuries Principles and treatment

Spinal injuries Principles and treatment. Presented By: Fadel Naim M.D. Orthopedic Surgeon Faculty of Medicine IUG. Background. Approximately half the injuries occur in the thoracic, lumbar, and sacral areas The other half occur in the cervical spine.

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Spinal injuries Principles and treatment

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  1. Spinal injuries Principles and treatment Presented By: FadelNaim M.D. Orthopedic Surgeon Faculty of Medicine IUG

  2. Background • Approximately half the injuries occur in the thoracic, lumbar, and sacral areas • The other half occur in the cervical spine. • The average age at injury is 32 years • 55% of those injured are aged 16-30 years • Approximately 80% of patients are male

  3. Spinal injuries can be described as: • Fractures • Fracture dislocations • SCIWORA / SCIWORET • Penetrating injuries

  4. All injuries can stable or unstable • All patients with x-ray evidence of injury and all those with neurologic deficitsshould be considered to have an unstable spinal injury.

  5. Blunt trauma • Motor vehicle accidents • Falls • Exlopsive injuries • Sport injuries

  6. Spine injuries can result from • Axial loading • Flexion • Extension • Rotation • Lateral bending • Distraction

  7. Spine Trauma suspect if • Head Trauma/ Loss of cosciousness • FFH • # calcaneum

  8. Initial management • The goals for the emergency physician are to: • Establish the diagnosis • Initiate treatment • Prevent further neurologic injury from either: • pathologic motion of the injured vertebrae • secondary injury from the deleterious effects of cardiovascular instability • respiratory insufficiency.

  9. Prehospitalcare: • stabilize and immobilize the spine on the basis of mechanism of injury, pain in the vertebral column, or neurologic symptoms. • Patients are usually transported to the ED with a cervical hard collar on a hard backboard.

  10. Initial management • ABCs & Immobilization • Rigid collar/ backboard • Airway/ ventilatory support • Hemodynamic support

  11. Beware • Excessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome

  12. Log rolling

  13. Spine Trauma: Clinical : Exam • Look • Skin: Bruise,Wound • Posture • Feel • Tender • Swelling • Bony landmarks • Do NOT move !!

  14. Initial management • Neurological exam: • performed as soon as the patient is hemodynamically stable: • Motor • Sensation • DTRs • digital rectal exam

  15. If patient is conscious: radiographs and full exam • spinal injury can be excludes if: • No pain • Normal clinical examination of spine • Normal neuro exam • If the patient is unconscious : • spinal injury unless proven otherwise……? • neuro exam…radiographs… other urgent surgeries…

  16. Initial Assessment Motor Examination • Upper extremity • C5-shoulder abduction • C6-wrist extension • C7-wrist flexion • C8-finger flexion • T1-finger abduction

  17. Initial Assessment Motor Examination • Lower extremity • L1-hip flexion • L2-hip adduction • L3-knee extension • L4-ankle dorsiflexion • L5-toe extension

  18. Initial Assessment • Dermatomes

  19. Reflex Examination

  20. Nerurogenic Shock vs Spinal Shock • Neurogenic shock results from impairment of the descending sympathetic pathways in the spinal cord resulting in loss of vasomotor tone and loss of sympathetic innervation to the heart • The result is: • Hypotension • Bradycardia

  21. Nerurogenic Shock vs Spinal Shock • Spinal Shock results immediately after severe cord injury • a state of diminished excitability of the spinal cord.. • Due to sudden withdrawal of a facilitating or excitatory influence from the supraspinal centers. • Areflexic flaccid paralysis • Hypotension • Bradycardia • Duration varies: avg 3-4w

  22. Clinical evaluation • Pain • Neurologic symptoms/signs • ASIA • Frankel scale • Image exams

  23. American Spinal Injury Association (ASIA) • A = Complete – No Sacral Motor / Sensory • B = Incomplete – Sacral sensory sparing • C = Incomplete – Motor Sparing (<3) • D = Incomplete – Motor Sparing (>3) • E = Normal Motor & Sensory

  24. Frankel Scale

  25. Investigations: • Imaging the spine does not take precedence over life-saving diagnostic and therapeutic procedures

  26. Image exams • Plain radiographs • Cheap and widely available • CT • 99% sensitivity for fracture • Quick • Disavantage – price and availability • MRI • Low specifity • Recommended to acces for injuries to soft tissue (ligamental, intervertebral disc, spinal cord injury) • Can distinguish betwen spinal cord edema and hemorrage • Very expensive • No better than CT as screening tool

  27. Trauma series includes X-ray for : • lateral cervical • Chest • lateral thoracic • A/P and lateral lumbar • A/P pelvis

  28. CT Scan • L3 unstable burst fracture

  29. MRI Scan • Thoracic fracture subluxation with increased signal in conus medullaris

  30. SCIWORA Spinal Cord Injury w/o Radiologic Abnormality • Spinal cord stretching leads to neuronal injury or even complete severing of the cord • Accounts for up to 70 % of ped. Spinal cord injuries • Most common in kids < 8 years • Paralysis may be present on arrival • Up to 30 % have a delayed onset of neurologic abnormalities • May not occur until up to 4-5 days after injury • Many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved

  31. SCIWORETSpinal cord injury without radiographic evidence of trauma • First described in pediatric population (SCIWORA) • In adults, tends to affect the elderly • Much more prevalent in cervical spine as opposed to the thoracolumbar area. • Related to the degenerative changes in the c-spine

  32. Classifications Necessary for…… • Uniform method of description • Directing treatment *** • Facilitating outcome analysis • Should be: Comprehensive Reproducible Usable Accurate

  33. Fracture Classification • Fracture classification allows organization and treatment of fractures through protocols developed to maximize patient outcomes • Most classification schemes based on criteria for describing stability • The mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment

  34. Anatomic Classification 2 or 3 Columns Denis ‘83 McAfee ‘83 Ferguson & Allen’84 Holdsworth’62 Kelley & Whitesides ’68

  35. Mechanical Stability • 3-column theory(Denis ‘83) • middle = posterior ½ VB, posterior disc, post longitudinal lig • Disruption of 2/3 unstable • 2-column theory (Holdsworth,’53) • anterior= VB, disc, ALL, PLL • posterior= neural arch, Post lig complex

  36. Anterior- Anterior longitudinal ligament, anterior half annulus fibrosus and vertebral body. Middle - Posterior longitudinal ligament, posterior half annulus fibrosus and vertebral body. Posterior - Osseous and ligamentous structures posterior to the posterior longitudinal ligament, (Interspinous ligaments)

  37. Spine Fracture Types Compression fractures • Result from axial loading and flexion • Failure of the anterior column • Middle, posterior columns intact • Usually stable unless > 50% height • Unlikely to be directly responsible for neurologic damage

  38. Burst Fractures • Axial load • Both anterior and middle columns fail • Retro-pulsion of bone and disk fragments into the canal • May cause spinal cord compression

  39. Fracture Dislocations • Fracture-dislocations • Most damaging of injuries • Failure of all three columns • Compression, flexion, distraction, rotation, or shearing forces

  40. Flexion- distraction • Seat belt–type injuries • Particularly where lap belts alone are used • Failure of both the posterior and middle columns • Intact anterior column prevents subluxation • Radiographic findings: • Increased height of the posterior vertebral body • Fracture of posterior wall of the vertebral body • Posterior opening of the disk space.

  41. Whiplash injury • Sudden hyperextension and flexion • Increasing neck pain for the first 24hours • Associated headache, pain radiating to both shoulders and paraesthesia in hands • Reduced lateral flexion • Anterior longitudinal ligaments are torn causes dysphagia • Forward flexion against resistance is painful • 90% are asymptomatic after 2years • 10% still have pain

  42. AP & lateral view radiographs of the lumbar spine demonstrates a narrowed T12 vertebral body height consistent with a compression fracture.

  43. Lumbar spine fractures and dislocations. Plain radiographs reveal a fracture of L2 with L2-L3 subluxation. CT scan. Note the large amount of bone retropulsed inside the spinal canal

  44. Scout view image from a spiral CT scan shows a complete subluxation fracture (curved blue lines) of the lower thoracic spine. Such an injury combines lateral displacement with rotational injury

  45. Treatment Non-operative Treatment Surgical Treatment Rehabilitation

  46. Goals of Non-operative Treatment • Preserve neurological function • Minimize deformity progression • Decrease pain • Restore Function ASSUMES THE SPINE IS STABLE

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