Spinal Injury


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1 : CME ON Spinal Injury And It’s Management 1 Prepared by - Dr. Md Nazrul Islam, MBBS, M.sc. Supervised by - Dr. Sk. Abbas Uddin Ahmed MS (Ortho), AO(Basic), AO(Spine). Presenting by - Dr. Abdul Hannan From - Department Of Orthopaedic & Traumatology, Shaheed Suhrawardy Medical College Hospital. Dhaka.
2 : Spinal Injury & its Management
3 : Over view Spinal Injury & its Management Definition of spinal injury Anatomy of human spine Classification of spinal injury Epidemiology Pathophysiology of spinal injury Clinical features of spinal injury Investigations Diagnosis Management Prognosis Rehabilitations Conclusions Functions of spine
4 : The spine has many functions, the main ones are listed below- 1.To provide protection of the spinal cord and associated nerves 2.To allow for movement 3.To support our body frame in an upright position  4. To allow for flexibility 5. To provide a structural foundation for the shoulder girdle and the pelvic girdles 6. To act as shock absorbers from load-bearing 7. To provide a structural base for rib attachments which protect the heart and lungs. Spinal Injury & its Management
5 : “ Spinal injury” may be defined as- Injury to the Spinal column (Bony Column)/Spinal Cord, or both of them. Spinal injury can be divided into- Spinal Column(Bony)Injury. Spinal Cord injury. Combined (Both Column & Cord) Injury. Definition Of Spinal Injury: Spinal Injury & its Management Spinal Injuries Spinal Column Injuries ± Injuries to Neural Structures (spinal cord, nerve roots)
6 : Spinal Column Injury Bony spinal injuries may or may not be associated with spinal cord injury These bony injuries include: Compression fractures of the vertebrae Comminuted fractures of the vertebrae Subluxation (partial dislocation) of the vertebrae Other injuries may include: Sprains- over-stretching or tearing of ligaments Strains- over-stretching or tearing of the muscles. 6 Spinal Injury & its Management
7 : Spinal Cord Injury Cutting, compression, or stretching of the spinal cord Causing loss of distal function, sensation, or motion Caused by: Unstable or sharp bony fragments pushing on the cord, or Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia. 7 Spinal Injury & its Management
8 : 9 Risk factors: Alcohol intoxication Drug abuse Participation in high- risk activities: Diving Contact sports Osteoporosis Epidemiology Spinal Injury & its Management 50% of SCI’s are complete 50-60% of SCI’s are cervical Immediate mortality for complete cervical SCI ~ 50% Occurs primarily in young males (> 75% of cases) Half of these injuries result from MVAs 2/3 of patients are < 30 years old Other sources of SCI: Falls, sporting and industrial accidents, gunshot wounds. Most common vertebrae involved are C5, C6, C7, T12, and L1 because they have the greatest ROM.
9 : 10 - 15 per million 18 - 35 years Male - 3:1 RTA 51% - cars Domestic 16% Industrial 11% Sports 16% - diving incidents Self harm 5% Epidemiology Incidence Spinal Injury & its Management
10 : Cervical 40% Thoracic 10% Lumbar 3% Dorso lumbar 35% Any 14% Types of Spinal Injury- Spinal Injury & its Management
11 : 11 Spinal Injury & its Management Incomplete injury: Some motor or sensory functions is spared distal to the cord injury. Voluntary sphincter contraction, toe flexor contraction –present. Prognosis-Good’ Complete injury: Total motor & sensory loss distal to the injury after Spinal shock (usually lasts for 24-48 hrs) is over. When the bulbo cavernosus reflex is positive & no sacral sensation or motor function has returned, paralysis will be permanent & complete in most patients.
12 : PATTERNS OF MULTIPLE SPINAL INJURY : Pattern: A. Primary lesion occur between C5 & C7 with secondary injuries at T12 or the lumber spine. Pattern : B. Primary injury at T2-T4 with secondary injury in cervical spine. Pattern : C.. Primary injury occur between T12 & L2 with secondary injuries from L4-L5.
13 : Acute: Caused by bone or ligament disruption that places the normal elements in danger of injury with any subsequent loading deformity. Chronic: Result of progressive deformity that may cause neurological deterioration. CLINICAL INSTABILITY
14 : 14 Degenerative Disease Of Spine Spinal Canal Stenosis Ankylosing Spondylitis Down's Syndrome Klippel-feil Syndrome Arnold-chiari Malformation Metastatic CA Osteomyelitis Rheumatoid Arthritis. Predisposing factors Spinal Injury & its Management
15 : Spinal Injury & its Management Spine consists of alternating Bony vertebrae Fibrocartilaginous disc Supported by musculature. Motion segment – Two adjacent vertebrae with intervening disc.
16 : Spinal Injury & its Management Anatomy of the spine is usually described by dividing up the spine (Bony vertebrae) into 3 major bony sections: The cervical, The thoracic, and The lumbar spine in which the spinal cord is embedded. (Below the lumbar spine is a bone called the sacrum, which is part of the pelvis). Each section is made up of individual bones called vertebrae. There are 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae.
17 : 5 Spinal Injury & its Management Anterior column = anterior 2/3 of the vertebral body, disc, and annulus, and the anterior longitudinal ligament) Middle column = posterior 1/3 of the vertebral body, disc, annulus, and the posterior longitudinal ligament Posterior column = pedicles, laminae, facets, capsule, and the interspinous and supraspinous ligament. injury is said to be stable if only one of the columns is involved. damage to two or more columns or risking neurological injury (ie damage to the middle column) - unstable. Stability of Spine-
18 : 8 Primary mechanism of cord injury can be due to four kinds of mechanical forces. a. Impact with persisting compression e. g. fractures, dislocations, and disc herniations. b. Impact with no persisting compression e. g. hyperextersion injuries. c. Distraction e. g. hyperflexion injuries. d. Laceration/ Transection: Penetrating injuries, fracture dislocation. Spinal Injury & its Management Most likely to occur at sites of maximum mobility Adults C6 Children <8 yrs old C2.
19 : Pathophysiology of spinal cord injury: Spinal Injury & its Management Secondary injury mechanisms that may be involved are: a. Systemic shock: Profound hypotension, and bradycardia (often lasting for days) follows cord injury and there may be a compromise of an already damaged cord. b. Local microcirculatory damage: may be due to mechanical disruption of capillaries, hemorrhage, thrombosis and loss of autoregulation. c. Biochemical damage: may occur due to excitotoxin release (glutamate), free radical production, arachidonic acid release, lipid peroxidation, eicosanoid production, cytokines and electrolyte shifts.
20 : 25% of spinal cord injuries occur after primary injury. Primary injury results from focal injuries (eg avulsion, contusion, laceration and intra-parenchymal hemorrhage) and diffuse lesions (e.g. concussive and diffuse axonal injury). Further mechanical disruption can result from external compression or angulation and ischemic damage from occlusion of arterial supply. Primary injury Spinal Injury & its Management
21 : Secondary injury Immediately after an acute spinal cord injury major reduction in blood flow occurs at the level of the lesion. Becomes progressively worse over the first few hours if left untreated. Pathophysiology underlying this ischaemia is unclear but involves both systemic and local effects. Putative local mechanisms include vasospasm, endothelial swelling or damage, haemorrhage causing obstruction of small blood vessels, loss of autoregulation and impaired venous drainage. 21 Results from: Cellular hypoxia Oligaemia Spinal Injury & its Management
22 : 22 Secondary injury- Spinal Injury & its Management Secondary Injury Cascade Current understanding
23 : Primary Neurological damage Direct trauma, haematoma & SCIWORA < 8yrs old In 4hrs - Infarction of white matter occurs In 8hrs - Infarction of grey matter and irreversible paralysis Secondary damage Hypoxia Hypoperfusion Neurogenic shock Spinal shock Spinal Injury & its Management
24 : Factors affecting the severity of a spinal lesion- Loss of neural tissue - obvious Vertical level – Higher up, the greater the damage Transverse plane – What Diameter has a lesion Spinal Injury & its Management
25 : Spinal Injury & its Management Pain Breathing difficulty Sensitivity to stimuli Muscle spasms Loss of sensation Loss of reflex function Loss of autonomic activity Loss of bowel control Loss of bladder control Sexual dysfunction Loss of function, such as mobility or sensation Paralysis Common features of spinal injuries are-
26 : “Level" of cord lesion is conventionally the most caudal location with normal motor and sensory function. Motor level = the last level with at least 3/5 (against gravity) function NB: this is the most important for clinical purposes Sensory level = the last level with preserved sensation Radiographic level = the level of fracture on plain XRays / CT scan / MRI NB: spine level does not correspond to spinal cord level below the cervical region. Spinal Injury & its Management
27 : Spinal shock may mimic a complete cord lesion with total loss of motor and sensory function distal to injury. However if lesion is incomplete some function will return 99% of patients with a complete lesion over 24 h will not show functional recovery Patients with partial lesion may regain substantial or even normal neurological function even though the initial neurological deficit may be severe Presence of bulbocavernous reflex or anal-cutaneous reflex indicates sacral sparing and a more favorable prognosis. Spinal Injury & its Management
28 : Spinal Injury & its Management A. Clinical laboratory tests.  Laboratory tests will be guided by clinical assessment of patient (history and physical examination). In addition to routine investigations diagnostic imaging is very important.  B. Diagnostic imaging.  X-RAY CT SCAN MRI
29 : Spinal Injury & its Management Indications for screening radiology. History of trauma and: Not fully conscious Drowsy or intoxicated Focal neurological deficit Midline cervical tenderness Other painful injury that may mask neck pain, particularly fractures Screening radiology of choice is CT of spine. Additional indications are- Extremes of age Mechanism of injury highly suggestive of cervical spine injury Significant facial trauma Sensitivity approximately 98% and considerably higher than plain radiography. May miss soft tissue injury and spinal cord injury in the absence of bony injury.
30 : Although CT may miss soft tissue and spinal cord injury, MRI is a sensitive alternative method. Almost never an emergency Exception: cauda equina syndrome Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan. Risk of transfer to MRI ability of MRI to detect soft tissue injury may fall after 72 hour. 25 Spinal Injury & its Management
31 : 25 Spinal Injury & its Management SCIWORA (spinal cord injury without radiologic abnormality) Incidence 3-5% (x-ray/CT) Higher incidence in paediatric population (34.8%)- The relatively large size of the head. inherent skeletal mobility. cord vulnerable to damage. Higher incidence above 60 yo- Posterior vertebral spurs due to spondylosis. Ligamentum flavum bulging due to loss of disc height. Risk of central cord syndrome after hyperextension injury.
32 : 20 History- 1. Mechanism of injury 2. Misdiagnosis - head injury, acute alcoholic intoxication and multiple injuries. 3.Decreased level of consciousness or comatose patients may not complain of neck pain. 4. Profuse bleeding from face and scalp may divert attention from cervical spine injury
33 : 21 General examination: a) Head and ear b) Spinous process and interspinous ligaments palpation c) Elbows may be flexed if a spinal cord injury causes loss of function below biceps and may be extended if the paralysis is higher. d) Penile erection and incontinence of the bowel and bladder- significant spinal injury. e) Flaccid paralysis of the extremities – Quadriplegia f) Chest abdomen and extremities – Other injuries.
34 : 22 Accurate and detailed neurological evaluation – very important Level of consciousness- Pupillary size and reaction, epidural or subdural haematoma, depressed skull fracture. Evaluation of sensory (pinprick), motor and reflex function. Important dermatome landmarks are- Nipple line –T4 Xiphoid process-T7 Umbilicus –T10 Inguinal region –T12,L1 Perineum and peri-anal region (S2,S3&S4)
35 : 35 Pre-Hospital Management. Hospital Management.
36 : Primary(Pre-hospital) management- 36 Initial treatment of patients with cord injury focuses on two aspects - preventing further damage and resuscitation. Immobilization with a hard cervical collar (in case of cervical spine injuries) and care in transportation of patient is of paramount importance if the spine is unstable. Resuscitation is aimed at airway maintenance, adequate oxygen saturation of peripheral blood, restoring blood pressure to acceptable limits, preventing bradycardia, done simultaneously to prevent any ischemic damage to the already compromised cord.
37 : Secondary (Hospital) Management: Medical Management Conservative (General)- Conservative (Medical)- Surgical Management Surgical Decompression Surgical Stabilization Fixation of Vertebra Fixation of Spine Artificial disc implantation Spinal Injury & its Management
38 : 32 Conservative(General)- Spinal Injury & its Management . Resuscitation according to ATLS guidelines Determination of neurological injury Prevention of neurological deterioration Ongoing ID & Tx of assoc injuries Prevention of complications Initiation of definitive management for vertebral column injury or SCI Immediate Management- Goals:
39 : Aim is to prevent extension of primary injury, to reduce secondary injury and to treat complications- Follow ATLS principles- 32 Conservative(General)- Spinal Injury & its Management A irway; protect Spine B reathing C irculation D isability, Dx and Rx shock E xpose patient And Treat Secondary survey.
40 : 40 Conservative(Medical)- Conservative treatments of spinal disorders have improved significantly over the years. Of the many conservative non-surgical treatments that are currently available, a few of the most commonly practiced treatments are - Epidural Steroid Injection Intradiscal thermoplasty (IDET) Nucleoplasty Facet Injections, and/or Medial Branch Blockade Radio Frequency Rhizotomy or Denervation. Spinal Injury & its Management
41 : Depending on the circumstances, when surgery is required. Surgery may be considered if the spinal cord is compressed and when the spine requires stabilization. The surgeon decides the procedure that will provide the greatest benefit for the patient. The common procedures which we perform are- Surgical Decompression Surgical Stabilization Spinal fusion Fixation of Vertebra Fixation of Spine Discectomy, foramenotomy and laminectomy(Some times needed). Artificial disc implantation. 41 Spinal Injury & its Management Surgical -
42 : Surgical Decompression and/ or Fusion- Indications Decompression of the neural elements (spinal cord/nerves) Stabilization of the bony elements (spine) Timing Emergent Incomplete lesions with progressive neurologic deficit Elective Complete lesions (3-7 days post injury) Central cord syndrome (2-3 weeks post injury).
43 : 43 Spinal Injury & its Management Surgical -
44 : 33 Surgical - Spinal Injury & its Management
45 : 33 Spinal Injury & its Management Surgical– Spinal fixation implants:
46 : Spinal Injury & its Management Skin Breakdown Osteoporosis and Fractures: Pneumonia, Atelectasis, Aspiration: Heterotopic Ossification: Spasticity: Autonomic dysreflexia: Deep vein thrombosis: Cardiovascular disease: Syringomyelia- Neuropathic/Spinal Cord Pain- Respiratory Dysfunction- Miscellaneous pressure sores, Greatly increase cost and morbidity Pokilothermia in patients with lesion above T1 hyponatraemia common in first week. There are many complications of spinal Injury, the followings are most common-
47 : Rehabilitation after spinal injury (SI) focuses on the patient learning how to live life when faced with physical, occupational, and emotional challenges. After SI, everything can change, and you can face many issues including mobility, regular exercise and maintaining a level of fitness, communication challenges, and activities of daily living. Rehabilitation may be accomplished at a hospital, outpatient clinic, home, or a combination. Spinal Injury & its Management
48 : 36 Accredited rehabilitation centers provide SCI patients with a team of professionals and many resources. Some of the professionals include: Occupational Therapist Physiatrist. Physical Therapist:  Rehabilitation Nurse. Speech and Language Pathologist. Therapeutic Recreational Specialist. Vocational Rehabilitation Therapist. Rehab Psychologist Spinal Injury & its Management
49 : 39 Spinal Injury & its Management
50 : 50 Prognosis The main determinant of outcome is the patient's neurological grade at the time of admission with patients having complete motor and sensory myelopathy showing the worst prognosis. Other predictive factors include rectal tone status, admission blood pressure and pulse status, reflexes, and medical and surgical management since injury. The time course of recovery is also prolonged and recovery itself often incomplete. Taking all grades and locations into considerations a study concluded that while the majority of cases improved within a year, even at 3 years post injury 23.3% continue to improve whereas 7.1% deteriorated. The trend continued in the 5th year post injury also with 12.5% and 5.5% respectively showing further improvement and late deterioration. Hence prolonged rehabilitation at a comprehensive spinal rehabilitation center is the management of spinal cord injuries. Spinal Injury & its Management
51 : 40 “Neurological disorders are the most complicated problems known to medical science today, and we require the best scientific minds and technology in order to find cures.”    W. Dalton Dietrich, Ph.D., scientific director, The Miami Project to Cure Paralysis Spinal Injury & its Management
52 : Pre-hospital & hospital both phases are equally important for SI management. Surgical intervention improves recovery period, quality of life and Rehab, reduces morbidity/ mortality . SI is neglected and poorly managed. Research is sparse and data is missing. The demographics, epidemiological pattern of SC in the developing world is different from the developed world and this should be considered while formulating polices for the SI in future. Trauma evacuation protocols need to be developed and pre hospital care of suspected SI patient should be improved. Regional and national spinal injury centers providing comprehensive treatment and multidisciplinary rehabilitation should be established. Spinal Injury & its Management
53 : From- Department Of Orthopedics’ & Traumatology Shaheed Suhrawardy Medical College Hospital. Spinal Injury & its Management
54 : 4/13/2011 54 Associate Prof. Dr. P. C. Debenath Associate Prof. Dr. Sheikh Abbas Uddin. Associate Prof. Dr. Ziaul Haq Associate Prof. Dr. Shamimul Haq Associate Prof. Dr. Monowarul Islam Associate Surgeon Dr. Md. Aminur Rahman Assistant Prof. Dr. Kazi Shamimuzzaman Assistant Prof. Dr. A T M Bahar Uddin Dr. Abdul Hannan And Dr. Md Nazrul Islam Resident Surgeon, Department of Orthopedic & Traumatology. Shaheed Suhrawardy Medical College Hospital. Sponsored By- Incepta Pharmaceuticals Ltd. Bangladesh. Special Thanks Are Due To- Spinal Injury & its Management

 

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