TRAUMA SARAF SPINAL

Wiryawan Manusubroto SpB,SpBS(K) SMF Bedah Saraf RSUP dr Sardjito

INTRODUCTION

ANATOMY PHYSIOLOGY
Spinal cord ends at L1 Three tracts can be readily assessed clinically. - The corticospinal tract - The spinothalamic tract - The posterior columns Complete spinal cord injury: no sensory or motor function below a certain level, Incomplete spinal cord injury: If any motor or sensory function remains, prognosis for recovery is much better.

 Thoracic and lumbar levels supply sympathetic nervous system fibers Cervical and sacral levels supply parasympathetic nervous system fibers

Dermatomes and Myotome

PATHOLOGY OF SCI
Primary Injury
occurs at the time of injury may result in
cord compression direct cord injury interruption in cord blood supply

Secondary Injury
occurs after initial injury may result from
swelling/inflammation ischemia movement of body fragments

Cord transection
Complete
all tracts disrupted cord mediated functions below transection are permanently lost determined ~ 24 hours post injury possible results quadriplegia paraplegia

CLINICAL CLASSIFICATION

Cord transection
Complete
all tracts disrupted cord mediated functions below transection are permanently lost determined ~ 24 hours post injury possible results quadriplegia paraplegia

Cord transection
Incomplete
some tracts and cord mediated functions remain intact potential for recovery of function Possible syndromes Brown-Sequard Syndrome Anterior Cord Syndrome Central Cord Syndrome

Incomplete Cord Injury

Injury to one side of the cord (Hemisection) Often due to penetrating injury or vertebral dislocation Complete damage to all spinal tracts on affected side Prognosis for recovery is variable

Brown Sequard Syndrome

Exam Findings
Ipsilateral loss of motor function motion, position, vibration, and light touch Contralateral loss of sensation to pain and temperature Bladder and bowel dysfunction (usually short term)

Brown Sequard Syndrome

Anterior Spinal Artery Syndrome

Supplies the anterior 2/3 of the spinal cord to the upper thoracic region caused by bony fragments or pressure on spinal arteries

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 are preserved

Anterior Cord Syndrome

Usually occurs with a hyperextension of the cervical region Exam Findings

weakness or paresthesias in upper extremities but normal strength in lower extremities varying degree of bladder dysfunction

Central Cord Syndrome

Injury to nerves within the spinal cord as they exit the lumbar and sacral regions
Usually fractures below L2 Specific dysfunction depends on level of injury

Exam Findings
Flaccid-type paralysis of lower body Bladder and bowel impairment

Cauda Equina Syndrome

Temporary loss of autonomic function of the cord

at the level of injury Usually results from cervical or high thoracic injury Effects may be temporary and resolve in hours to weeks Presentation Flaccid paralysis distal to injury site Loss of autonomic function hypotension or relative hypotension vasodilation loss of bladder and bowel control priapism loss of thermoregulation warm, pink, dry below injury site relative bradycardia

Neurogenic Shock

Effect on other Organ Systems

Hypoventilation due to the paralysis:
Intercostal muscles Diaphragm

The inability to perceive pain may mask a potentially serious injury elsewhere:
Abdominal injury no abdominal tenderness Lower extremity injury

Compression Flexion Extension Rotation Lateral bending Distraction Penetration Rearback - Fall > 10 feet

Mechanism Of Injury ( High Energy )

ABCs
Airway and/or Breathing
Inability to maintain airway Apnea Diaphragmatic breathing Cardiovascular impairment Shock Hypotension and or bradycardia Patient appears warm and dry Hypoperfusion Level of consciousness

GENERAL ASSESMENT

Inspection and palpation: Occiput to Coccyx

Tenderness to the vertebrae Gap or Step-off (both very rare) Edema and bruising Spasm of associated muscles

Neurological assessment
Motor Sensation Reflexes

CLINICAL EVALUATION

NEXUS Criteria: 1. Absence of tenderness in the posterior midline 2. Absence of a neurological deficit 3. Normal level of alertness (GCS score = 15) 4. No evidence of intoxication (drugs or alcohol) 5. No distracting injury/pain

NEXUS

Any patient who fulfilled all 5 of the criteria were considered low risk for Cspine injury and as such did not need C-spine radiography For patients who had any of the 5 criteria, radiographic imaging was indicated in the form of AP, lateral, and odontoid Cspine views

NEXUS

Imaging Options
Initial Screening Options:
Plain films Lateral, AP, and Odontoid, Optional: Oblique and Swimmers (if necessary) CT- much better than plain films for bony fractures/dislocations. Poor evaluation of ligamentous injuries.

Other cervical spine imaging options

MRI- Very good for soft tissue/ligamentous injuries. Flexion-Extension Plain Films- to determine stability (may replace MRI if unavailable or contraindicated)

AP/LATERAL/SPECIAL VIEW
Anterior subluxation of one vertebra on another indicates facet dislocation Less than 50% of the width of a vertebral body implies unifacet dislocation Greater than 50% implies bilateral facet dislocation This is usually accompanied by widening of the interspinous and interlaminar spaces

X-ray Guidelines (cervical) Mnemonic AABBCDS Adequacy, Alignment Bone abnormality, Base of skull Cartilage, Disc space Soft tissue

Radiological Evaluation

Thin cut CT scanning should be used to evaluate abnormal, suspicious or poorly visualized areas on plain radiology The combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%

CT Scanning

Ideally all patients with an abnormal neurological examination should be evaluated with an MRI scan Patients who report transient neurological symptoms but who have a normal exam should also undergo an MRI assessment of their spinal cord

MRI

Spinal injuries can be described as, Fractures Fracture dislocations SCIWORA Penetrating injuries Injuries can be stable or unstable All patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury until proven otherwise.

Morphology

Stable vs Unstable Fractures

Stability of cervical spine is provided by two functional vertical columns
Anterior column: vertebral bodies, the disc spaces, the anterior and posterior longitudinal ligaments and annulus fibrosus Posterior column: pedicles, facets and apophyseal joints, laminar spinous processes and the posterior ligament complex

As long as one column is intact the injury is stable.

Primary Goal
Prevent secondary injury

Stabilization of the spine begins in the initial assessment

Treat the spine as a long bone
Secure joint above and below

Caution with partial spine splinting

Immobilization vs Motion Restriction

MANAGEMENT OF CORD

General Precaution
Spinal Motion Restriction: immobilization devices ABCs
Increase FiO2 Assist ventilations as needed with cervical spine control Indications for intubation:acute respiratory failure, Glasgow score <9, increased respiratory rate with hypoxia, PCO2 more than 50, and vital capacity less than 10 mL/kg IV Access & fluids titrated to BP ~ 90-100 mm Hg

Look for other injuries: Life over Limb Transport to appropriate SCI center once stabilized

Consider High Dose methylprednisolone:

30 mg/kg bolus over 15 mins After bolus: infusion 5.4mg/kg IV for 23 hours Controversial as recent evidence questions benefit Must be started < 8 hours of injury Most spine surgeons do not use for penetrating trauma

TRAUMA : MECHANISM ? ABC AND D PEX

UNCONSIOUSNE SS ALERT ( NEED ICU/INTUBATED)

D
SSX+

CARDINAL SSXNO NEED IMAGING

(IF PLEGIA , DISTINCT FROM SPINAL SHOCK)

SSX

IS UNCLEAR CLARIFY !

FLOWCHART 1

SSX+ (>+1)

IMAGING AP,LAT,SPESIFIC PLAIN X RAY

PLAIN X RAY NEGATIF

PLAIN X RAY POSITIF

C
STABEL UNSTABEL

VASCULAR PROBLEM ?

CLEARENCE BY EXPERT /CT/MRI

FLOW CHART B

STABEL
IS DECOMPRESSION NEEDED

UNSTABEL

STABILIZING

STABILIZING IS PURSUIT DEPEND ON LAST CONDITION OF STABILITY

DECOMPRESSION IF NEEDED

FLOWCHART C

ENTIRE SPINAL EVALUATION AP/LAT CERVICAL 3 D CT CERVICAL-THORACAL AP/LAT THORACOLUMBAR

FLOWCHART D

Points to Remember:
Maintain cervical spine immobilization until spine properly evaluated Criteria exist (NEXUS ) that identify the need for cervical spine imaging
Patients negative for either criteria may have their spine clinically cleared

Screen patients with plain radiograph or CT

CT better than plain radiographs

MATUR NUWUN