LARONA HYDRAVIANTO

Department of Surgery RSUD SIDOARJO

MANAGEMENT OF SPINAL INJURY

IntroductionSPINAL CORD INJURY (SCI)

18 - 35 years Global :25

0.000 - 500.000 people suffer every year

40- 80 cases per million population

Male : female= 4 : 1

Spinal Column Function

Anatomy

• Vertebral column- 7 cervical- 12 thoracic- 5 lumbar- 5 sacral - 4 coccygeal

Spinal cord 31pairs of

spinal nerves are attached to the spinal cord :

- 8 cervical - 12 thoracic - 5 lumbar - 5 sacral - 1 coccygeal

The dorsal roots of spinal nerves contain afferent (or sensory) fibers

The ventral roots of spinal nerves contain efferent (or motor) fibers

Goal of Spine Trauma Care

• Obtain healed & stable spine

Principles of Diagnosis and Management

Spinal Immobilization

Spinal Immobilization

Spinal Immobilization

Contraindications to neutral position

LESS MOVEMENT IS BEST

Helmet RemovalTechnique• 2 Rescuers• Remove face mask and chin strap• Immobilize head

Slide one hand under back of neck and headOther hand supports anterior neck and jaw

• Remove helmetGently rock head to clear occiput

• All actions should be slow and deliberate

Diagnosis

Radiographic Imaging

NEXUS• NEXUS Criteria :

1. Absence of tenderness in the posterior midline2. Absence of a neurological deficit3. Normal level of alertness (GCS score = 15)4. No evidence of intoxication (drugs or alcohol)5. No distracting injury/pain

fulfilled all 5 of criteria low risk for C-spine injury No need C-spine X-ray

any of the 5 criteria radiographic imaging was indicated (AP, lateral and open mouth views)

Radiolographic Evaluation

X-ray Guidelines (cervical) AABBCDS

• Adequacy, Alignment• Bone abnormality, Base of skull• Cartilage• Disc space• Soft tissue

Adequacy

Alignment• The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities

• Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation

• A step-off of >3.5mm issignificant anywhere

Lateral Cervical Spine X-Ray

• Anterior subluxation of one vertebra on another indicates facet dislocation– < 50% of the width of a

vertebral body unilateral facet dislocation

– > 50% bilateral facet dislocation

Bones

Disc

• Disc Spaces– Should be

uniform

• Assess spaces between the spinous processes

Soft tissue

• Nasopharyngeal space (C1)– 10 mm (adult)

• Retropharyngeal space (C2-C4)– 5-7 mm

• Retrotracheal space (C5-C7) – 14 mm (children)– 22 mm (adults)

AP C-spine Films• Spinous processes should

line up

• Disc space should be uniform

• Vertebral body height should be uniform. Check for oblique fractures

Open mouth view

• Adequacy: all of the : all of the dens and lateral dens and lateral borders of C1 & C2borders of C1 & C2

• Alignment: lateral : lateral masses of C1 and C2masses of C1 and C2

• Bone : Inspect dens for lucent fracture lines

CT Scan• Thin cut CT scan should be

used to evaluate abnormal, suspicious or poorly visualized areas on plain film

• The combination of plain film and directed CT scan provides a false negative rate of less than 0.1%

• Unable to adequately assess on plain films

• Sagittal and/or coronal reconstructions can be helpful (particularly at Occipitocervical and C-T junction.)

MRI

Principle of treatment

• Spinal column alignment– deformity/subluxation/dislocation

reduction

• Spinal column stability– unstable stabilization

• Neurological status– neurological deficit decompression

Spinal shock• Temporary loss of all or most spinal reflex

activity below level of injury• Lasts around 24 hours (max 48 hrs)• Ends when bulbocavernosus reflex and/or

anal wink returns • An injury cannot be considered complete

until resolution of spinal shock

• Autonomic function/ loss of sympathetic ( hypotension, bradycardia) neurogenic shock

Pharmacologic Pharmacologic TTreatment reatment of Spinal Cord of Spinal Cord IInjurynjuryNational Acute Spinal Cord injury Study

(NASCIS) II :• methylprednisolone (within 8 hours):

significantly better neurologic recovery • after 8 hours: worst outcome (relatively

high rate of complications) NASCIS III : improved recovery when tx extended to 48

hours (if drug therapy was started within 3 to 8 hours)

Pharmacologic Pharmacologic TTreatment reatment of Spinal Cord of Spinal Cord IInjurynjuryDosage :

– 30 mg/kg of IV methylprednisolone (for 1 hour)

– followed by 5.4 mg/kg (administered over the next 23 hours)

– if administered within 3 hours of injury– when is initiated 3 to 8 hours after injury

: maintained for 48 hours

Jefferson Fracture

• Burst fracture of C1 ring• Unstable fracture• Increased lateral ADI on

lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view

• Need CT scan

Burst Fracture

• Fracture of C3-C7 from axial loading

• Spinal cord injury is common from posterior displacement of fragments into the spinal canal

• Unstable

Optimal treatment of cervical burst fractures is anterior corpectomy, decompression, reconstruction, and plating

Clay Shoveler’s Fracture

• Flexion fracture of spinous process

• C7>C6>T1• Stable fracture

Flexion Teardrop Fracture

• Flexion injury causing a fracture of the anteroinferior portion of the vertebral body

• Unstable because usually associated with posterior ligamentous injury

- Surgical intervention is almost always indicated- Anterior neural decompression in the form of corpectomy, followed by reconstruction with strutgraft or cage as well as static anterior cervical plating and posterior-instrumented arthrodesis

Bilateral Facet Dislocation

• Flexion distraction injury• High incidence of spinal

cord injury• Extremely unstable

Hangman’s Fracture

• Extension injury• Bilateral fractures

of C2 pedicles (white arrow)• Anterior dislocation

of C2 vertebral body (red arrow)

• Unstable

Odontoid Fractures

• Generally unstable• Type 1 fracture through the

tip– Rare

• Type 2 fracture through the base– Most common

• Type 3 fracture through the base and body of axis– Best prognosis

Thoracic and Lumbar Fractures

Stability of The Spine

Instability may cause :1. Mechanical problem

Compression fracture that lead to kyphotic deformity.

2. Neurological disturbance Extraction of the bone fragment into spinal canal → regression of the neurological function.

Both can happen together

Denis Three Column Concept

Denis classification of thoracolumbar fractures

Surgical treatment is indicated for :

Compression fracture• Result from an axial loading

force acting on a flexed spine

• Usually stable• Can be treated nonsurgically• Bracing for 6 weeks with

subsequent physical therapy led to a better outcome than casting for 6 – 12 weeks

Burst fracture

• Burst fracture with more than 50% height loss, 30° of kyphosis, or a neurologic deficit riginally were identified as unstable and requiring surgical treatment

• PLC is important in determining the stability

• The goal of treatment of is to prevent the progression of deformity and neurologic injury

Burst fracture

• Hyperextension cast or thoracolumbosacral orthosis for 8 – 12 weeks

• Surgical option : - Posterior approach - Anterior approah - Combined anterior-posterior approach

Stable Burst fracture

Unstable Burst fracture

Flexion distraction (Chance fracture)

Translation-rotation injuries

• Highly unstable shear injury or fracture-dislocation

• Requiring surgical stabilization

Fracture-dislocation