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Spinal Trauma

Spinal Trauma. Samuel Kim, M.D., M.Div. September 12, 2006. Introduction. 40 y.o. male falls off a 12 foot high roof and lands on his back Not able to feel or move his lower extremities C-collared, boarded and sent to the nearest trauma center 10 mg Morphine given en route. Introduction.

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Spinal Trauma

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  1. Spinal Trauma Samuel Kim, M.D., M.Div. September 12, 2006

  2. Introduction • 40 y.o. male falls off a 12 foot high roof and lands on his back • Not able to feel or move his lower extremities • C-collared, boarded and sent to the nearest trauma center • 10 mg Morphine given en route

  3. Introduction • Initial trauma survey: • Airway: intact • Breathing: clear b/l, equal, no crepitus • Circulation: BP160/90, 2+ pulses x 4 • Disability: no sensation or motor below umbilicus • Exposure

  4. MRI

  5. Introduction • Pt suffered a burst fracture of T7 and T8 • No change in condition over next several days • Eventually sent to rehabilitation • Poor prognosis: permanent paraplegia

  6. Statistics • 10,000 - 20,000 spinal cord injuries per year • Incidence • ~ 82% occur in men • ~ 61% occur in 16-30 y.o. • Common causes • MVC (48%) • Falls (21%) • Penetrating injuries (15%) • Sports injuries (14%)

  7. Statistics • 40% of trauma patients with neuro deficits will have temporary or permanent SCI • Many more vertebral injuries that do not result in cord injury • Most commonly injured vertebrae • C5-C7 • C1-C2 • T12-L2

  8. Statistics • Average cost of caring for permanent paraplegics and quadriplegics • Over five billion dollars per year • Not all are Christopher Reeves • Costs ultimately paid by tax payers

  9. Introduction • As first responders: • Can play a significant role in minimizing secondary spinal cord injuries

  10. Anatomy • 33 Vertebrae • Spine supported by pelvis

  11. Anatomy • Cervical Spine • 7 vertebrae • Very flexible • C1: atlas • C2: axis

  12. Thoracic Spine 12 vertebrae Ribs connected to spine Provides rigid framework of thorax Anatomy

  13. Anatomy • Lumbar Spine • 5 vertebrae • Largest vertebral bodies • Carries most of the body’s weight • Sacrum • 5 fused vertebrae • Coccyx • 4 fused vertebrae • “Tailbone”

  14. 31 pairs Cervical 1-8 Thoracic 1-12 Lumbar 1-5 Sacral 1-5 Coccygeal 1 Carry both sensation and motor function Spinal Cord

  15. Dermatome • Specific area in which the spinal nerve controls • Useful in assessment of specific level of SCI

  16. Dermatome • C 3, 4 • Motor: shoulder shrug • Sensory: top of shoulder • C 5, 6 • Motor: elbow flexion • Sensory: thumb

  17. Dermatome • C 7 • Motor: elbow, wrist, finger extension • Sensory: middle finger • C8, T 1 • Motor: finger abduction & adduction • Sensory: little finger • T4 • Motor/sensory: level of nipple • T 10 • Motor/sensory: level of umbilicus

  18. Dermatome • L 1, 2 • Motor: hip flexion • Sensory: inguinal crease • L 3, 4 • Motor: quadriceps • Sensory: medial thigh, calf • L 5 • Motor: great toe, foot dorsiflexion • Sensory: lateral calf

  19. Dermatome • S 1 • Motor: knee flexion • Sensory: lateral foot • S 4 • Motor: anal sphincter tone • Sensory: perianal

  20. Assessment of Spinal Injury • Consider Mechanism of Injury • High speed MVA • Fall from significant height • Stabbing • Gun shot • Sports injury • Football

  21. Assessment of Spinal Injury • Airway • Breathing • Circulation • Disability • Exposure

  22. Neurologic Status • Check level of consciousness. • Cooperative? • Intoxicated? • Able to communicate? • Recall the events?

  23. Assessment of Function & Sensation • Palpate over spinous processes • Motor function • Arm and leg movements • Sensation • Position • Pain

  24. Spinal Cord Injuries • Direct traumatic injury • Stab • Gunshot • Excessive Movement • Acceleration • Deceleration • Deformation

  25. Spinal Cord Injuries • Directional Forces • Flexion • Extension • Rotational • Lateral bending • Vertical compression • Distraction

  26. Compression Fracture

  27. Wedge Compression Fracture • Flexion injury

  28. Burst Fracture • Another flexion injury with posterior involvement

  29. Chance Fracture • Flexion-distraction injury • Typically seatbelt injury in high speed MVA • Involves: • Spinous process • Lamina • Transverse processes • Pedicles • Vertebral body

  30. Chance Fracture

  31. Chance Fracture

  32. Primary Injury • Occurs at the time of injury • May result in • Cord compression • Direct cord injury • Interruption in cord blood supply • Not much can be done

  33. Secondary Injury • Occurs after initial injury • May result from • Dwelling/inflammation • Ischemia • Movement of body fragments • First responders can play a significant role in reducing these injuries!

  34. Cord Transection • Complete • Cord functions below transection are permanently lost • Results in quadriplegia or paraplegia

  35. Complete Cord Transection

  36. Complete Cord Transection

  37. Cord Transection • Incomplete • Some cord mediated functions remain intact • Potential for recovery of function • Brown-Sequard Syndrome • Anterior Cord Syndrome • Central Cord Syndrome • Posterior Cord Syndrome

  38. Brown Sequard Syndrome • Injury to one side of the cord • Often due to penetrating injury or vertebral dislocation • Complete damage to all spinal tracts on affected side • Good prognosis for recovery

  39. Brown Sequard Syndrome • Exam Findings • Ipsilateral loss of motor function motion, position, vibration, and light touch • Contralateral loss of sensation to pain and temperature

  40. Brown Sequard Syndrome

  41. 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 preserved

  42. Anterior Cord Syndrome

  43. Central Cord Syndrome • Usually occurs with a hyperextension of the cervical region • Weakness or paresthesias in upper extremities but normal strength in lower extremities • Varying degree of bladder dysfunction

  44. Central Cord Syndrome

  45. Posterior Cord Syndrome • Good muscle strength • Normal pain and temperature sensation • Difficulty in coordinating limb movements

  46. Posterior Cord Syndrome

  47. Cauda Equina Syndrome • Injury to nerves within the spinal cord as they exit the lumbar and sacral regions • Usually fractures below L2 • Flaccid-type paralysis of lower body • Bladder and bowel impairment

  48. Pictures

  49. Neurogenic Shock • From physiologic and anatomic transection or near-transection of the spinal cord • Leads to flaccid paralysis • Hypotension due to vasomotor instability • Patients will be warm • No tachycardia

  50. Spinal Shock • Caused by severe trauma to the spinal cord • Flaccid quadriplegia with areflexia • Need 24-48 hours before determining long-term prognosis • May spontaneously resolve

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