Kuliah Mahasiswa Spinal Cord Injury Terbaru

7/27/2019 Kuliah Mahasiswa Spinal Cord Injury Terbaru

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TRAUMA MEDULASPINALIS

Dr. Rendra leonas SpOTORTHOPAEDIC SPINE SURGEON

DEPARTMENT OF SURGERY

MOH. HOESIN PALEMBANG


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Introduction

Most common

age and high speed level

traffic accident >>80% spinal inj not assoc SI

more important preliminary care


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At least 5% of patients

With spinal cord injuries

Worsen neurologically at

hospital.


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Introduction

Trauma spine can cause damaged :

Hard tissue : bone

Soft tissue : ligamentdiscus

spinal cord


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Introduction

Careful Physical Examination is potentially

the most valuable service a physician can

provide to the patient. ( OKU Spine : 2004 )

Complete exam :

Correct diagnosis

Magnitude of the problemDetermine appropriate Treatment


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Anatomy and Physiology

33 bones comprise the spine Function

Skeletal support structure

Major portion of axial skeleton

Protective container for

spinal cord

Vertebral Body Major weight-bearing

component

Anterior to other

vertebrae components


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Characteristic of the

Vertebrae

Cervical

C-1 & C-2 novertebral body

Support head

Allow for turning of

head Vertebral body size

increase inferiorly theybecome


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Characteristic of

theVertebrae

Lumbarspine has

strongest andlargest

weight bearing of

the body

Sacral & Coccyx

vertebrae are fused

No vertebral body


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Components ofVertebrae

Spinal Canal Opening in the

vertebrae that thespinal cord passesthrough

Pedicles

Thick, bony structuresthat connect thevertebral body to thespinous andtransverse processes


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Components of Vertebrae Laminae

Posterior bones of vertebrae that make up foramen

Spinous Process Posterior prominence on vertebrae

Intervertebral Disks Cartilagenous pad between vertebrae

Serves as shock absorber

Transverse Process Bilateral projections from vertebrae

Muscle attachment and articulation location with ribs


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Intervertebral Disc

nucleus

pulposus

annulus

fibrosus

hyaline cartilage

end plates


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Facet Joints

Act to limit shear and torsion

motions between vertebrae

Orientation of facet changes

along length of spine

Cervical : couple lateral

bending and torsional

motion

Thoracic : coronal plane

orientation of joint surfaces

Lumbar : sagital planeorientation of joint surfaces

Facets carry 10-20% of

compressive load in upright

standing, >50% of anterior

shear load in forward fexion


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SPINAL NERVES 31 pairs of spinal nerves :

8 cervical

12 thoracic

5 lumbar

5 saccral

1 coccygeal

Each has both motor and sensory fibers Motor fibers = anterior or ventral root

Sensory fibers = posterior or dorsal root


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OVERVIEW

LOOK

inspection

FEEL palpation

MOVE

active & passive

movements


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Look :

bruise

hematom

wound : gun shoot wound

stab wound

Deformity

EXAMINATION : STANDING


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EXAMINATION :STANDING

Feel : Tenderness: may be bony, intervertebral or

paravertebral

Bony prominence or stepsspinous processes using C7 &/or L4-5

as landmarks

facet joints approx. 2cm lateral to spinous processes


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Feel :

assess alignment, mobility &

tenderness of: transverse processes of vertebrae

lateral to spinous processes



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EXAMINATION :STANDING

Feel : Tenderness: may be bony, intervertebral or

paravertebral

Bony prominence or stepsspinous processes using C7 &/or L4-5

as landmarks

facet joints approx. 2cm lateral to spinous processes


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Feel :

assess alignment, mobility &

tenderness of: transverse processes of vertebrae

lateral to spinous processes



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Signs of nerve root

compression

Standard full neurological examination of

both lower limbs :

tone, power (MRC grading) sensation (light touch, pinprick &

proprioceptive if indicated)

reflexes (physiologic and patologic)

an anatomical distribution [dermatome(s) or

myotome(s)]


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Neurological Examination

Objectives :

Determine if defect is present

Localize the level of the deficit

Include :

Sensory

Motor

Reflex


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Sensory examination Explain, eyes closed

Examine : touch, 2 point discrimination,

proprioceptive.

Sensory dermatomes, compare each

opposite


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Sensory Dermatome


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Muscle Power Grading

0 - complete paralysis

1 - flicker of contraction possible

2 - movement is possible when gravity is

excluded

3 - movement is possible against gravity

4 - movement is possible against gravity + some

resistance 5 - normal power


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Motor examination Muscle grading

Compare each side

Cervical :

Scapular C4Deltoid & Biceps C5Wrist extension & supination C6Wrist flexion & Pronation C7


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Motor

examination

Lumbo-sacralHip flexorHip extensor

L 1,2,3

S1Knee flexor

Knee extensor

L 4,5, S1,2L 2,3,4

Ankle flexorAnkle extensor S1L5


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ReflexesBiceps Triceps

Brachioradialis Hoffman

PROVOCATIVE TESTS


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PROVOCATIVE TESTSTEST COMMENTS

SLR : sitting & supine Must produce radicular symptom in the distribution of theprovoked root, for sciatic nerve , that means pain distal to knee

Lasgue's sign SLR radiculopathy aggravated by ankle dorsoflexion

Contralateral SLR Well-leg SLR puts tension on involved root from opposite direction

Kernig's test The neck is flexed chin to chest. The hip is flexed to 90, and thenthe leg is the extended similar to SLR; radiculopathy is reproduced

Bowstring sign SLR radiculopathy aggravated by applying pressure over poplitealfossa.

Femoral stretch test Prone patient; examiner stretch femoral nerve roots to test L2-L4irritation

Nafziger's test Compression of neck vein for 10 s with patient lying supine ;coughing then reproduces radiculopathy

Milgram's test

Patient raises both legs off the examining table and hold thisposition for 30 s; radiculopathy maybe reproduced


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Denis 3 Column Theory

Denis, F.: The Three-Column Spine and its Significance in theClassification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)


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Basic Types of Spine Fractures

1. Compression fracture

2. Burst fracture DenisClassification


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3. Seat-belt injury (Flexion-distraction

injury)

Bony Chance fracture Soft tissue Chance injury


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4. Fracture-dislocation

Flexion-rotation Flexion-distraction

Anterior posterior shear


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Classification spine fracture

Location :

1. Jefferson fracture

2. Dens fracture3. Hangmans fracture

4. Clay shovelers fracture

5. SCIWORA


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Compression fracture

Failure of the anterior column

Mechanism anterior or lateral flexion

Normally Stable or unstable fracture Rarely involved neurologic comprimise


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Criteria unstable

Loss of 50% of vert body height

Angulation of thoracolumbar junct > 20deg

Mutiple adjacent column of spine

Failure of 2/3 of column of spine


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Chance fracture

Anterior column falls in tension (along w/

the middle and posterior columns)

Three columns rupture in distraction

(tension)

Seldom assc w/ neurologic comprimise

unless

Unstable


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Burst fracture

Compressive failure of vert body both

anteriorly & posteriorly , w/ failure of both

anterior & middle columns

Axial loading applied to intravertebral disc

results in increased nuclear pressure and

hoop stresses in the annulus


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Burst frx location

Cervical burst fix

Lumbar burst fix Thoracic burst fix

Thoracolumbar burst fix


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Classification :

Stable frx

- neurologically intact- poterior arch remains intact : pedicl

widening implies post arch disruption

- less than 50% anterior body height- compression fracture


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Unstable frx

- neurologic defisit

- loss of 50% vertebral body height- fracture dislocation

- thoracolumbar burst frx


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Jefferson Fracture

Pediatric frx

- frx proceeds thru open synchondroses,

and may occur w/ minimal trauma/- posterior synchondroses fuses at age 4

- anterior synchondroses fuses at age 7


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Mechanism

- original description in 1920 noted role of

axial compression- may also be caused by hyperextension,

causing a posterior arch fracture


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Associated injuries

- approx 1/3 of these fractures are

associated with a axis fracture- approx 50% chance that some other

C-spine injury is present

- low rate of neurologic deficits is due tolarge breadth of C1 canal


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Radiographs

Odontoid view

Lateral view

Flexion and extension views

CT scan


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Dens Fracture

Odontoid fractures are the most common

upper cervical spine fratures

Remember rule of thirds cervical cord

occupies a 1/3 of canal, dens occupies a

1/3 and the remaining 1/3 is empty

Mechanism

Flexion loading

Extension loading


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Classification

Type I

Type 2 Dens frx

Type 3


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Associated Injury

Atlas frx

Transverse ligament rupture

Pharangeal injury

H f /T ti


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Hangmans frx/Traumatic

Spondylolisthesis of the Axis

Fix of pars interarticularis of C2 & disruption of C2-C3

junction

Type of traumatic spondylolisthesisHangmans frx

Term Hangmans fracture is not accurate for the majority

of cases, because mechanism of injury for clinically

encountered frx often lacks large traction force present in

judicial hangings


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In cases in which there is neurologic

injury, there will usually be significant

horizontal translation w/ accompanying

damage to the posterior longitudinalligament w/ or w/o damage of the C2 C3

interspace


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Mechanism of injury in adults

Judical lesion : hyperextension and distraction

Hyperextension w/ vertical compression ofposterior column, & translation of C2 and C3

Forceful extension of already extended neck

is most commonly described mech of injury,

but other causes include flexion of flexed neck

& compression of an extended neck

A blow on the forehead forcing the neck into

extension is a classic mechanism of injuryproducing fractures thru the pedicles of C2

known as traumatic spondyloslishthesis of C2


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SCIWORA Syndrome

Occurs may often in pediatric population

Accounts for up to 2/3 of severe cervical

injuries in children < 8 years of age

Inherent elasticity in pediatric cervical

spine can allow severe spinal cord injury

to occur in absence of x-ray findings


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Radiographs

Diagnosis of exclusion

MRI may give a more anatomic diagnosis by

showing hemorrage or edema of the spinalcord

Pseudosubluxation : anterior displacement

may be up to 4 mm

Clasification spinal cord


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Clasification spinal cord

injury Complete

Incomplete

Anterior cord syndrome

Central cord syndrome

Brown sequad

Cauda equina

A t


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Anatomy

crossection spinal cordAscending Tract

Tracts of Goll and Burdach

(fasc gracilis and cuneatus

Proprioception,vibration,dis

crimination

uncrosssed

Dorsal and ventral

spinocerebellar tract

Proprioception, light touch uncrossed

Lateral spinothalamic tract Pain, temperature crossed

Spinal olivary tract Tendon and muscle

proprioception

crossed

Ventral spinothalamic tract Deep tactile and pressure

sensation

crossed

Descending Tract

Lateral corticospinal tract

(pyramidal)

Motor control uncrossed

Rubrospinal tract Cerebellar reflexes crossed

Lateral reticulospinal tract Inhibits locomotor conytrol crossed

Reticulospinal tract Facilittes locomotor control uncrossed

Vestibulospinal tract Postural control Uncrossed

Tectospinal tract Eye and ear reflleces crossed

Complete / incomplete Spinal


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Complete / incomplete Spinal

Cord Lession

Complete cord injury : there is complete loss of

sensation and muscle function in the body below

the level of the injury

An injury to the upper portion of the spinal cord

in the neck can cause quadriplegia-paralysis of

both arms and both legs. If the injury to thespinal cord occurs lower in the back it can cause

paraplegia-paralysis of both legs only.


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Incomplete lesion : there is some

remaining function below the level of theinjury. In most cases both sides of the

body are affected equally.

Present when there is any distal sparing of

motor or sensory function along with

sparing of perirectal sensation


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Diff dx of incomplete lesions

Central cord syndrome Brown sequard syndrome

Anterior cord syndrome

Posterior cord syndrome Isolated nerve root injury

Cauda equina syndrome (w/ or w/o root

escape)

Conus medullaris injury


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Anterior Cord Syndrome

Damage is primarily in theanterior 2/3 of cord and is

related to vascular insuffiency

There is sparing the posterior

columns

Syndrome is manisfested by

complete motor paralysis

(corticospinal func) and

sensory anesthesi

(spinothalamic func)

Patient demonstrates greater

motor loss in the legs than

arms


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Prognosis

anterior cord syndrome has the worst prognosisof all cord syndromes

prognosis is good if recovery is evident &

progressive during first 24 hours

after 24 hrs, if no signs of sacral sensibility to

pinprick or temp are present,

prognosis for further functional recovery are

poor; only 10 to 15% of patients demonstratefunctional recovery;

Central Cord Syndrome


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Central Cord Syndrome

most common incomplete cord lesion

frequently associated w/ extension injury

to osteoarthritic spine (cervical

spondylosis) in middle aged person whosustains hyperextension injury

cord is injured in central gray matter, &

results in proportionally greater loss ofmotor function to upper extremities than

lower extremities w/ variable sensory

sparing;
http://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesionhttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injurieshttp://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injurieshttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/cervical_spondylosishttp://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesion


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Anatomy:

fibers responsible for lower extremitymotor and sensory functions are located in

the most peripheral part of the cord

whereas fibers controlling the upperextremity and voluntary bowel and bladder

function are more centrally located

sacral tracts are positioned on theperiphery of the cord & are usually spared

from injury;


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Mechanism of Injury:

hyperextension injury

central cord injury and hemorrhage occur

with compression of adjacent white-matter

tracts more peripheral positioning of lower

extremity axons within the spinal cord

tracts accounts for the injury pattern
http://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injurieshttp://www.wheelessonline.com/ortho/hyperextension_injuries_19_38_of_cervical_injuries


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damage to central portion of corticospinal

and spinothalamic long tracts in white

matter produces upper motor neuron

spastic paralysis of trunk and lowerextremity


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Examination

central cord syndrome is remarkable formore cord involvement in the upper

extremities than in the lower extremities

manifests w/ loss of distal upper extremitypain & temperature sensation and

strength, w/ relative preservation of lower

extremity strength & sensation


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upper extremities:

mixed upper and lower-motor-neuron lesion, w/

partial flaccid paralysis of upper extremities

(indicative of involvement of lower motor neurons)

prognosis is variable w/ poor hand function

lower extremities:

spastic paralysis of lower extremities (indicative of

involvement of upper motor neurons) bladder and bowel function may also be lossed;

Brown Sequard Syndrome


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Brown Sequard Syndrome

type ofincomplete cord syndrome

injury to either side of spinal cord

produces ipsilateral muscle paralysis

(from corticospinal tract injury) andcontralateral hypersthesia to pain and

temperature (from spinothalamic injury)
http://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesionhttp://www.wheelessonline.com/ortho/incomplete_spinal_cord_lesion


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syndrome results from hemitransection of

spinal cord w/ unilateral damage to the

spinothalamic & corticospinal tracts and

resultant loss of ipsilateral motor & dorsalcolumn function & of contralateral pain and

temperature sensation

often due to penetrating trauma orunilateral facet fracture ordislocation;
http://www.wheelessonline.com/ortho/unilateral_facet_dislocationhttp://www.wheelessonline.com/ortho/unilateral_facet_dislocation


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Prognosis:

this syndrome has a good prognosis for

recovery

more than 90% of pts regain bladder &

bowel control & ability to walk

most patients will regain some strength in

lower extremities and most will regain

functional walking ability;;

Cauda Equina Syndrome


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Cauda Equina Syndrome

urinary retention is the most consistent

finding

in spinal cord injuries, the caudal equina

may sustain considerable initial trauma

in any potential cauda equina syndrome it

is important to examine for saddle

anesthesia, rectal tone, bulbocaverosusreflex, and sacral sparing;
http://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/sacral_sparinghttp://www.wheelessonline.com/ortho/sacral_sparinghttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflexhttp://www.wheelessonline.com/ortho/bulbocavernosus_reflex


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Initial Evaluation

ABC

Airway, Breathing, Circulation and C-spine

Back board with C-spine immobilization

C-spine lateral x-ray

Management of neurogenic shock

Vascular hypotension with bradycardia

Volume replacement, vasopressor

Avoid pulmonary edema from fluid overload

Associated life-threatening injuries


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Spinal Shock

Usually < 24 hrs

Check for BulboCavernosus reflex!!!


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Image Study

Plain x-ray

Vertebral height

Focal kyphosis

Level and type of injuryAbove T9 spinal cord injury

T10 to L1 spinal cord or rootinjury

Below L2 root injury

Computed tomography

Canal compromise

Myelography, MRI


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Neurologic Deficits1

Complete vs. Incomplete Injury?

Sacral sparing Incomplete injury


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Frankel Classification

A. Absent motor and sensory function

B. Sensation present, motor function

absent

C.Sensation present, motor function

active but not useful (grade 2-3/5)

D.Sensation present, motor function

active and useful (grade 4/5)E. Normal motor and sensory function


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ASIA Classification


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Neurologic Deficits

High dose methylprednisolone

30 mg/kg bolus IV injection in 1st hour

5.4 mg/kg/hr continuous IV infusion since 2

nd

hour

Given in 3 hours after injury: maintain 24-hr

therapy

Given beyond 3 hours after injury: maintain 48-hrtherapy

Given beyond 8 hours after injury: no benefit!!!

S


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Surgical Treatment

Indications:

Neurological deficits (+)

Neurological deficits (-)

Fracture-dislocations

Burst fractures

Anterior vertebral height collapse >50%

Focal kyphosis > 30

Canal compromise > 50%

Sagittal index (SI) > 25

S i l T


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Surgical Treatment

Goals:

To create an optimal environment for

neural recovery

To ensure stabilization and early

mobilization

To minimize further neurological

compromise from late deformity


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Kuliah Mahasiswa Spinal Cord Injury Terbaru