CASE REPORT TETRAPLEGI E.C SPONDILOLYSTESIS Vt.

C6-7

Name : Suriana Dwi Sartika C 111 07 154

Mentors : dr. Adriansyah Amri dr. Denal B.T

Supervisor dr. Karya Triko Biakto, Sp.OT (K) Spine

Orthopedic and Traumatology Department Hasanuddin University 2012

PATIENT IDENTITY Name Age Sex RM Date of admittance : Tn. R : 28y.o : Male : 00 54 24 : 11/10/12

HISTORY TAKING Chief complaint: cant move the lower limb and difficult to move the upper limb. It suffered since 9 days before admitted to hospital because traffic accident. Patient also feel pain at the back. Mechanism of trauma: the patient was a passenger of a truck , when the truck hit a big stone and make its rolling into the canyon, patient fall with unclear mechanism. Prior treatment at RS.Jayapura History of unconsciussness (+), vomitting (-), nausea (-) Micturation: patient cant feel micturation Defecation: patient cant feeldefecation

GENERAL STATUS Counscious / Moderate illness/ good nourished BP HR RR T : 120 / 80 mmHg : 96 x/mnt : 20 x/mnt : 36,7 C

LOCAL STATUS Cervical region Inspection Palpation :Deformity (+), swelling (-), hematoma (-),wound (-) :Tenderness (+) at C6-7, step off (-)

Clinical Picture

NEUROLOGICAL STATUS

REFLEX Physiologic Reflex R Bisep Trisep Patella (+) (+) (-) L (+) (+) (-) (-)

Achilles (-)

Pathologic Refleks R Hoffman Tromner Babinski Chadock Openheim (-) (-) (-) (-) L (-) (-) (-) (-)

Rectal Touche : anal contraction (-), ampulla fill by feses, smooth mucosa HS: feses (+), blood (-), mucous (-) Bulbocavernosus reflex (+)

LABORATORY FINDINGS WBC RBC HGB HCT PLT CT BT HBsAg Na K Cl GOT GPT Ureum Kreatinin GDS 7,7 x 103 /uL 3,84 x 106 /uL 11,5 g/dL 29,9 % 140 x 103 /uL 8'00'' 4'00'' negatif 133 mmol/ml 4,0 mmol/ml 103 mmol/ml 17,8 U/L 14,2 U/L 81,3 mg/dl 0,7 mg/dl 80 mg/dl

RADIOLOGY FINDINGS

Cervical AP-Lateral X-Ray

Thoraks AP X-Ray

Pelvis AP X-Ray

CT-Scan Cervical

MRI Cervical

DIAGNOSIS Tetraplegi due to spondilolistesis Vt. C6-7

TREATMENT In line immobilization Apply neck collar Apply skull traction Planning for stabilization

Cervical AP-Lateral XRay (after skull traction)

RESUME A 28 years old man, came to hospital with chief complaint cant move lower limb and difficult move the upper limb since 9 days ago before admitted to hospital , because traffic accident. Patient also feel pain at the back. . Prior treatment at RS.Jayapura Micturation: patient cant feel micturation Defecation: patient cant feeldefecation Physical examination: deformity and tenderness (+) C6-7 Neurological examination: motoric at the lower limb is total paralysis and motoris at upper limb is decrease. Sensoric of below T4 area is absent and sensoric of C6 until T2 area is impairment. Reflex for patella and achiless is absent, pathological reflex (-) Radiological findings :subluksasi anterior CV C6 terhadap C7 (<50%) dengan tanda-tanda dislokasi facet

DISCUSSION
Anatomy of Spine

Consist of 33 vertebrae : 7 cervical (lordosis) 12 thoracic (kifosis) 5 lumbal (lordosis) 5 sacral (kifosis) 4 conccygeal (lordosis).

Anatomy Root exit spinal column via intervertebral foramen C1-7 : exit above their vertebra C8-L5 : exit below their vertebra (C7 exit above C7 vertebra and C8 exit below C7 vertebra) Medula spinalis end at L1 (Conus Medullaris) Lumbar and sacral nerve form cauda equina in spinal canal before exit below vertebrae

Spinal Cord

Spinothalamic tract

Anterior and lateral portion of the cord that transmit sensations of pain and temperature. Light touch sensation is carried primarily in the ventral spinothalamic tract. These tracts cross shortly after entering the spinal cord and therefore transmit sensations from the contralateral side of the body.

Corticospinal tract

Descending tract in lateral portion of the cord Transmits ipsilateral motor function. The anterior corticospinal tract is a crossed tract, which facilitates skilled movements.

Denis Theory

Anterior : ALL + 2/3 of vertebral body/anulus Middle : PLL + 1/3 of vertebral body Posterior : Pedicles, lamina, spinous process, and ligaments

SPINAL TRAUMA Spinal trauma divided by : Upper cervical Lower cervical Thoracic and lumbar fracture Sacral fracture

Lower cervical spine fractures and dislocations are common injuries following major trauma (about 40%). Spinal cord damage is more frequently associated with lower rather than upper cervical spine fractures and dislocations.

Classification : Anterior column injury Posterior column injury Lateral column injury

Traumatic Cervical Spondylolisthesis Spondylolisthesis means forward of one segment of the spine upon another. Normal disc, laminae, and facers constitute a locking mechanism that prevents each vertebra from moving forward on the one below.

Facet dislocation Facet dislocations represent a wide range of injuries because they may be unilateral, bilateral, and with or without facet facture. Many other associated injuries such as disc herniation and posterior ligamentous complex disruption may exist. In addition, neurologic injury is common and there is significant potential for neurologic deterioration.

Unilateral facet dislocation This is a flexionrotation injury in which only one apophyseal joint is dislocated. There may be an associated fracture of the facet. Cord damage is unusual and the injury is stable

X-Ray : on the lateral x-ray the vertebral body appears to be partially displaced (less than onehalf of its width); on the anteroposterior x-ray the alignment of the spinous processes is distorted. Management is the same as for bilateral facet dislocation. Sometimes complete reduction is prevented by the upper facet becoming perched upon the lower. After reduction, if the patient is neurologically intact the neck immobilized in a halo vest for 6-8 weeks. However, about 50 percent of patient surgery may still have to be considered at the end of the period.

Bilateral facet dislocation Bilateral facet joint dislocations are caused by severe flexion or flexionrotation injuries. The inferior articular facets of one vertebra ride forward over the superior facets of the vertebra below. One or both of the articular masses may be fractured or there may be a pure dislocation jumped facets. The posterior ligaments are ruptured and the spine is unstable; often there is cord damage. X-Ray : The lateral x-ray shows forward displacement of a vertebra on the one below of greater than half the vertebras antero-posterior width. The displacement must be reduced as a matter of urgency. Skul traction used startinng 5 kg and increasing it step-wise by similar amounts up to about 30 kg. neurological examination should be

repeated after each incremental step. If it increase, further attempts at close reduction should be stopped.

Mechanism of injury Traction (avulsion) Direct injury Indirect injury

Pathophysiology Primary changes . Physical injury may be limited to the vertebral column, including its softtissue components, and varies from ligamentous strains to vertebral fractures and fracturedislocations. The spinal cord and/or nerve roots may be injured, either by the initial trauma or by ongoing structural instability of a vertebral segment. Secondary changes. During the hours and days following a spinal injury biochemical changes may lead to more gradual cellular disruption and extension of the initial neurological damage. Spinal injuries may damage both bone and soft tissue (ligaments, facet joint capsule and intervertebral disc). For example : flexion-distraction with bilateral facet dislocation and disruption of the posterior ligaments and disc heal with fibrous tissue and can become completely stable

Assesement History Mechanism of injury and symptoms of cervical pain, numbness, weakness, or parasthesias. Physical examination Asses spinal tenderness (logrolling), sweeling, hematom, gaps between spinosus process Neurological examination Motoric and sensory functiom Refleks examination Perineal function

Motor Examination: Measures the strength of 5 key upper & 5 key lower extremity myotomes according to the Medical Research Council grading scheme of 0 5 The final but most important motor function to be tested is voluntary anal contraction. Sensory Examination: Assessing light touch & pinprick sensation along 28 dermatomes.

 Sensation is documented as either absent (0), impaired (1) or normal (2). Assess sensation in lowest sacral segments from DRE, whether anal sensation is preserved

Sensoric Examination

Reflex Examination

Perianal function Sacral sparing should be tested for. Preservation of active great toe flexion, active anal squeeze (on digital examination) and intact peri-anal sensation suggest a partial rather than complete lesion. In cervical cord injuries the perineal function may be initially absent, but the bulbocavernosis reflex may return in several days, indicating resolution of spinal shock, which is an initial depolarization of axonal tissue after injury. If the patient has not made any distal recovery at this time, the prognosis is grave.

General examination-shock Three types of shock may be encountered in patients with spinal injury : Hypovolaemic shock is suggested by tachycardia, peripheral shutdown and, in later stages, hypotension. Neurogenic shock reflects loss of the sympathetic pathways in the spinal cord; the peripheral vessels dilate causing hypotension but the heart, deprived of its sympathetic innervation, does not respond by increasing its rate (paralysis, warm and well-perfused peripheral areas, bradycardia and hypotension with a low diastolic blood pressure suggests Spinal shock occurs when the spinal cord fails temporarily following injury. Below the level of the injury, the muscles are flaccid, the reflexes absent and sensation is lost. This rarely lasts for more than 48 hours

Early management The adherence to the resuscitation protocol (airway with cervical spine control, breathing, circulation and haemorrhage control) supersedes the assessment of the spinal injury. Adequate oxygenation, ventilation and circulation will minimize secondary spinal cord injury. Immobilization of cervical spine : In-line immobilization The head and neck are supported in the neutral position. Patient with no neurological injury Stable injuries If the spinal injury is stable, the patient is treated by supporting the spine in a position that will cause no further strain; a firm collar or lumbar brace will usually suffice, but the patient may need to rest in bed until pain and muscle spasm subside.

Unstable injuries If the spinal injury is unstable it should be held secure until the tissues heal and the spine becomes stable. In the cervical spine this should be done as soon as possible by traction, using tongs or a halo device attached to the skull. Patient with neurological injury If the spinal injury is stable (which is rare), the patient can be treated conservatively and rehabilitated as soon as possible. With the usual unstable injury, conservative treatment can be still be used; this is highly demanding and is best carried out in a special unit equipped for round-the-clock nursing, 2hourly turning routines, skin toilet, bladder care and specialized physiotherapy and occupational therapy.

Principle of definitive treatment The objectives of treatment are: to preserve neurological function; to minimize a perceived threat of neurological compression; to stabilize the spine; to rehabilitate the patient The indications for urgent surgical stabilization are: an unstable fracture with progressive neurological deficit and MRI signs of likely further neurological deterioration controversially an unstable fracture in a patient with multiple injuries.

Treatment methods 1. Collars Soft collar offer very little biomechanical supprot to the cervical spine and their use restricted to minor sprain. Rigid collar limit motion quite effectively and rare widely used in the acute setting. 2. Tongs 3. Halo ring. At least four pins are inserted into the outer table of the skull and a ring is applied.

4. Fixation

THANK YOU ........