dr. Muh. Andry Usman, SpOT

Department of Orthopaedic and Traumatology Faculty of Medicine

Hasanuddin University

Spinal injury can lead to spinal cordinjury

Spinalcordinjurycanleadto:ParaplegiaQuadriplegiaDeath

10,00020,000spinalcordinjuriesperyear Incidence~82%occurinmen~61%occurin1630yoa

CommoncausesMVC(48%)Falls(21%)Penetratinginjuries(15%)Sportsinjuries(14%)

40% of trauma patients with neuro decitswillhavetemporaryorpermanentSCI

Many more vertebral injuries that do notresultincordinjury

MostcommonlyinjuredvertebraeC5C7C1C2T12L2

Education inproperhandlingandmovementcandecreaseSCI

PrimaryInjuryPreventionPublicEducationEMSCommunityServiceProjects

SecondaryInjuryPreventionFirstResponderCareEMSCareTertiaryHospitalCare

33VertebraeSpinesupportedbypelvis key ligaments and muscles connect head to

pelvisanteriorlongitudinalligamentanteriorportionofthevertebralbodymajorsourceofstabilityprotectsagainsthyperextension

posteriorlongitudinalligamentposteriorvertebralbodywithinthevertebralcanalpreventshyperexion

BoneStructureoftheSpine

Cervical

Lumbar

Thoracic

Sacral/Coccyx

CervicalSpine7vertebraeveryexibleC1:alsoknownastheatlasC2:alsoknownastheaxis

ThoracicSpine12vertebraeribsconnectedtospineprovidesrigidframeworkofthorax

LumbarSpine5vertebraelargestvertebralbodiescarriesmostofthebodysweight

Sacrum5fusedvertebraecommontospineandpelvis

Coccyx4fusedvertebraetailbone

Vertebral body posterior portion forms part of vertebral

foramen increases in size from cervical to sacral spinous process transverse process

Vertebral foramen opening for spinal cord

Intervertebral disk shock absorber (fibrocartilage)

Ends at ~ L-2 cauda equina

Blood supplied by vertebral and spinal arteries

Gray matter: core pattern\ resembling butterfly

White matter: longitudinal bundles of myelinated nerve fibers

SpinalCordThoracic and lumbar levels supply

sympatheticnervoussystembersCervical and sacral levels supply

parasympatheticnervoussystembers

AscendingNerveTracts(sensoryinput) carry impulses from body structures and sensory

informationtothebrain Posteriorcolumn(dorsal)

conveys nerve impulses for proprioception, discriminativetouch,pressure,vibration,&twopointdiscrimination

crossoveratthemedullafromonesidetotheothere.g.impulsesfromleftsideofbodyascendtotherightsideofthebrain

SpinothalmicTracts(anterolateral)Convey nerve impulse for sensing pain,

temperature&lighttouch Impulses cross over in the spinal cord not the

brainLateraltracts

conduct impulses of pain and temperature to thebrain

Anteriortractscarryimpulsesoflighttouchandpressure

DescendingMotorTracts(motoroutput)ConveysmotorimpulsesfrombraintothebodyPyramidaltracts:Corticospinal&CorticobulbarCorticospinaltracts

destined to cause precise voluntary movement andskeletalmuscleactivity

lateraltractcrossesoveratmedulla

To thalamus and cerebral cortex (sensory)

Brain Stem

Spinal Cord

Pain - Temp Proprioception (conscious)

Spinothalmic tract

Example Motor Pathway (corticospinal tract)

LMN

Motor Cortex

Corticospinal tract

Posterior column

31pairsoriginatefromthespinalcordCarrybothsensationandmotorfunctionNamedaccordingto levelofspinefromwhere

theyariseCervical18Thoracic112Lumbar15Sacral15Coccygeal1

Dermatome Specicareainwhichthespinalnerve

travelsorcontrols Useful in assessment of specic level

SCI Plexus

peripheral nerves rejoin and functionasgroup

CervicalPlexusdiaphragmandneck

LEVEL SENSATION MOTOR REFLEX

C5 Lateral arm (axilarry patch) Deltoid Biceps

C6 Lateral forearm Wrist extension, biceps Brachioradialis

C7 Middle finger Triceps, wrist flexors, finger extension Triceps

C8 Small finger Finger flexors None

T1 Medial arm Interossei None

LEVEL SENSATION MOTOR REFLEX L1 Anterior thigh Psoas (T12,L1,L2,L3) None

L2 Anterior thigh, groin Quadriceps (L2,L3,L4) None

L3 Anterior and lateral thigh Quadriceps (L2,L3,L4) None

L4 Medial leg and foot Tibialis anterior Patellar

L5 Lateral leg and dorsal foot Extensor hallucis longus None

S1 Lateral and plantar foot Gastroenemius, peroneals Achilles

S2-24 Perianal Bladder and foot intrinsics None

Most important spinal injury indicator

Suddendecelerations(MVCs,falls) Compressioninjuries(diving,fallsontofeet/

buttocks) Signicantblunttraumaaboveclavicles Very violentmechanisms (explosions, cave

ins,lightningstrike)

Paininspineorparaspinalarea Pain in back of head, shoulders, arms,

legs Absent, altered sensation (numbness,

paresthesias, loss of temperature,position,touchsense)

Absent , a l tered motor funct ion(weakness,paralysis)

Diaphragmaticbreathing(paralysisofchestwall)

Shockwithslowheartrateanddryskin Incontinence Priapism

Neurologic decits are a result of cordinjury

Spinal injury without cord involvementmay produce no signicant signs andsymptoms

TraditionalApproachBasedonMOIEmphasisonspinalimmobilizationin

unconscioustraumavictimspatientswithamotioninjury

NoclearclinicalguidelinesorspeciccriteriatoevaluateforSCI

Signspain,tenderness,painfulmovementdeformity,injuryoverspinalarea,shockparesthesias,paresis,priapism

ABCsAirwayand/orBreathingimpairmentInabilitytomaintainairwayApneaDiaphragmaticbreathing

CardiovascularimpairmentNeurogenicShockHypoperfusion

NeurologicStatus:LevelofConsciousness

Braininjuryalso?CooperativeNoimpairment(drugs,alcohol)Understands&RecallseventssurroundinginjuryNoDistractinginjuriesNodicultyincommunication

AssessFunction&SensationPalpateovereachspinousprocessMotorfunctionShrugshouldersSpreadngersofbothhandsandkeepapartwith

forceHitchhike{T1}Footplantarexors(gaspedal){S1,2}

Sensation(PositionandPain)weakness,numbness,paresthesiapain(pinprick),sharpvsdull,symmetry

Priapism

ForcesDirecttraumaticinjury

staborgunshotdirectlytothespine

ExcessiveMovement acceleration deceleration deformation

DirectionalForces exion,hyperexion extension,hyperextension rotational lateralbending verticalcompression distraction

Can have spinal column injury with or without

spinal cord injury

PrimaryInjury occursatthetimeof

injury mayresultincordcompressiondirectcordinjury interruptionincord

bloodsupply

SecondaryInjuryoccursafterinitialinjurymayresultfromswelling/inammation ischemiamovementofbody

fragments

Cordconcussion&Cordcontusiontemporarylossofcordmediatedfunction

Cordcompressiondecompressionrequiredtominimizepermanent

injuryLacerationpermanentinjurydependentondegreeof

damageHemorrhagemayresultinlocalischemia

Cordtransection Complete alltractsdisrupted cordmediatedfunctionsbelowtransectionare

permanentlylost determined~24hourspostinjury possibleresults

quadriplegia paraplegia

Paraplegialossofmotorand/or sensory

function in thoracic, lumbaror sacral segments of SC(armfunctionisspared)

Quadriplegialossofmotorand/orsensory

function in the cervicalsegmentsofSC

CordtransectionIncompletesometractsandcordmediatedfunctionsremainintactpotentialforrecoveryoffunctionPossiblesyndromes

BrownSequardSyndrome AnteriorCordSyndrome CentralCordSyndrome Posteriorcordsyndrome

IncompleteCordInjury Injurytoonesideofthecord(Hemisection)Often due to penetrating injury or vertebral

dislocationCompletedamagetoallspinaltractsonaected

sideGoodprognosisforrecovery

ExamFindingsIpsilateral loss of motor function motion,

position,vibration,andlighttouchContralateral loss of sensation to pain and

temperatureBladder and bowel dysfunction (usually short

term)

AnteriorSpinalArterySyndromeSupplies the anterior 2/3 of the spinal cord to

theupperthoracicregioncausedbybonyfragmentsorpressureonspinal

arteries

ExamFindings Variable loss of motor function and

sensitivitytopinprickandtemperature lossofmotorfunctionandsensationtopain,

temperatureandlighttouch Proprioception (position sense) and

vibrationarepreserved

Usuallyoccurswithahyperextensionofthecervicalregion

ExamFindings Weaknessorparesthesiasinupperextremities

butnormalstrengthinlowerextremities varyingdegreeofbladderdysfunction

Injury to nerves within the spinal cord astheyexitthelumbarandsacralregions UsuallyfracturesbelowL2 Specicdysfunctiondependsonlevelofinjury

ExamFindings Flaccidtypeparalysisoflowerbody Bladderandbowelimpairment

Picture 2

TemporarylossofautonomicfunctionofthecordatthelevelofinjuryUsually results from cervical or high thoracic

injuryDoesnot always involvepermanentprimary

injuryEects may be temporary and resolve in

hourstoweeksGoalistoavoidsecondaryinjury

PresentationFlaccidparalysisdistaltoinjurysiteLossofautonomicfunctionhypotensionorrelativehypotensionvasodilation lossofbladderandbowelcontrolpriapism lossofthermoregulationwarm,pink,drybelowinjurysiterelativebradycardiamay have class SNS response presentation above

injury

PrimaryGoalPreventsecondaryinjury

StabilizationofthespinebeginsintheinitialassessmentTreatthespineasalongboneSecurejointaboveandbelow

Cautionwithpartialspinesplinting ImmobilizationvsMotionRestriction

Neutralpositioningofheadandneckifatallpossible allowsforthemostspaceforcord moststablepositionforspinalcolumn dontforceit

CervicalMotionRestriction Manualmethod Rigidcollarcomeslater Interimdevice(KED) Movetolongboardorfullbodyvacuumsplint Manualcontinuesuntiltrunkandheadsecured CIDDontusesandbagsorIVuidbagsasheadblocksTapeworkswonders! Improvisewithblanketrolls

DontforgetthePadding Maintainsanatomicalposition Limitsmovementonboardespeciallyduringtransportonboardorinvehicle

llallthevoids curvatureofthelowerbackisnormalllitpillows,blankets,towelsTapealong(evenducttape)isnotenough

SecuringtotheBoardStraps,Tape,Cravats,whateverTorsorstthenlegsandfeetandhead

EvenpatientsextricatedwithaKEDaresecuredtotheboard

PediatricPatientConsiderationsElevatetheentiretorsoiflargeocciputPadunderneathShortboardunderneathVacuummattress

LotsofvoidstollDiculttondacorrectlysizedrigidcollarImprovisewith

horsecollarblanketortowelrolls

HelmetedPatientsRemovalshouldbelimitedtoemergentneedfor

accesstoairwayandventilationLeaveinplaceifgoodtwithlittleornoheadmovementwithinnoimpendingairwayorbreathingproblemscanperformspinalmotionrestrictionwithhelmetonnointerferenceinairwayassessmentormanagementnocardiacarrest

HelmetedPatientsTypesofHelmetsSports(football,hockey)

ShoulderpadsandhelmetgotogetherRacing(motorcycle,carracer)Recreational(motorcycle,bicycle)

Various helmets create dierent problems forpatientandforremoval

GeneralManualSpinalMotionRestrictionABCs

IncreaseFiO2AssistventilationsprnIVAccess&uidstitratedtoBP~90100mmHg

ConsiderHighDosemethylprednisolone[SoluMedrol]:30mg/kgbolusover15minstheninfusionafter1sthour

Lookforotherinjuries:LifeoverLimbTransporttoappropriateSCIcenter

AbsenceofpainortendernessofthespineLackofneurologicdecitsNormallevelofconsciousness

Includesabilitytounderstandcause&eectAbletomakeownhealthcaredecisions

NoevidenceofalcoholordruguseNodistractinginjuries

Thank You